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The following are excerpts from the newsletter

July 11, 2001

  • Patient safety is all about taking that extra step.
  • Suggestions for resolving conflicts in drug therapy.
  • ISMP Quarterly Action Agenda: April - June, 2001
  • Safety Briefs:
    • There is a developing nomenclature issue with LANTUS [insulin glargine (rDNA origin)], a new insulin product approved for use in both type 1 and type 2 diabetes mellitus.
    • Seventeen reports of medication errors due to confusion between SERZONE (nefazodone), an antidepressant, and SEROQUEL (quetiapine), used for psychotic disorders.
    • An article in the July, 2001 Hospital Pharmacy shows that vincristine is stable when diluted to 20-50 mL. Such dilutions can help in preventing inadvertent fatal intrathecal injection since it makes it look different than typical intrathecal drugs which are usually given in volumes of 10 mL or less.
    • A mix-up between AVANDIA (rosiglitazone maleate), an antidiabetic agent, and COUMADIN (warfarin). The patient says he developed a GI bleed and required a bowel resection.
    • A "heads up" to look at current procedures for securing needle disposal boxes in patient care areas. According to a reporter, there have been several arrests made in the Kansas City, KS after patients stole boxes from nursing units in order to extract leftover narcotics from used syringes.

July 25, 2001

  • The supermarkets do it - so why can't we raise the "bar" in health care?
  • A hospital recently reported a situation where house staff incorrectly ordered AGGRASTAT (tirofiban) when they meant to order argatroban.
  • Safety Briefs:
    • A patient with renal failure was given a dose of vancomycin along with orders to administer another 1 g dose intravenously if his vancomycin level the next morning was "less that 10." The symbol for "less than" was written in a way that made the number 10 look more like 40.
    • An office nurse telephoned a prescription to a community pharmacy for "Trydesogen-28," giving directions for the patient to take one tablet daily. The pharmacist called to clarify the order. The nurse decided to check with the doctor, who was overheard in the background saying, ". no, no, I said to try DESOGEN (ethinyl estradiol and desogestrel)."
    • The Agency for Healthcare Research and Quality (AHRQ) released a 640-page report last week, detailing evidence-based practices known to improve patient safety. The AHRQ report lists more than 70 practices, including the top eleven proven practices yet to be widely adopted by hospitals.
    • At one hospital, if items were not available commercially in unit dose packaging, a 24-hour supply was placed in a single, zip-lock bag and sent in a patient drug bin with the drug cart each day at 1500. It became apparent that some nurses, familiar with unit dose packages that hold only one dose, might have confused the contents of the multi-dose zip-lock bags as a unit dose package.
    • The free ePocrates qRx drug database ( is a database that provides adult and pediatric dosing, dosage strengths, drug interactions, adverse reactions and contraindications, metabolism and excretion, and pregnancy and lactation information

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