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July 13, 2006

• Practitioners agree on medication reconciliation value, but frustration and difficulties abound
• Exubera: risk of dosing errors.

Instructions and labeling of the new inhaled insulin, EXUBERA (insulin human [rDNA]), poses serious risk of dosing errors.

• Acute phosphate nephropathy.

The FDA recently notified healthcare professionals and consumers regarding reports of acute phosphate nephropathy associated with oral sodium phosphates used for bowel cleansing.

• Using technician errors as an opportunity for change.

A survey of over 800 pharmacy technicians reported that interruptions and inadequate staffing were among the most frequent factors perceived to contribute to technician medication preparation errors.

• Community education

Partnering of Patient Empowerment Through Community Awareness (PPECA) has created a free program for educating consumers about healthcare safety.

Special Announcements…

• August teleconferences.

Join ISMP for our August 3 teleconference, 2006-2007 JC Update: Requirements Related to Medication Use.  The teleconference will be repeated on August 10.

• Webinar

The Nursing Leadership Congress is sponsoring a free webinar on August 2 entitled, Using Human Centered Design to Improve Patient Safety. The program is intended for senior nursing leaders and explores the nurses’ role in designing safe practices. For details visit: www.nursingleadershipcongress.com/nursingcongress/webinars.asp

July 27, 2006

• ISMP comments on IOM report, Preventing Medication Errors
• Worth Repeating...More on “double keying” errors

Infusion pump “double keying” errors have been reported with various types of pumps. We recently learned about a double keying incident that resulted in infusion of TPN at 445 mL/hr, instead of 45 mL/hr, for 4 hours before a rapid response team uncovered the error.

• Luer accepts oral syringe

When the right amount of force is applied, BD Q-SYTE Luer Access Split-System Devices, used to cap peripheral and central venous access lines, have the potential to be accessed by an oral syringe.

• “Triptans” and SSRIs/SNRIs

FDA notified health professionals and consumers last week about the risk of serotonin syndrome when combining 5-hydroxytryptamine receptor agonists (triptans) with selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SNRIs).

• Inhaled insulin delayed

The release of EXUBERA inhalation powder (insulin human [rDNA origin]) will be delayed until September to allow more time for provider education.

• ISMP Quarterly Action Agenda

The April-June 2006 ISMP Quarterly Action Agenda appears in the PDF version of the newsletter. Subscribers can also download a Word version of the Action Agenda (www.ismp.org/Newsletters/acutecare/actionagenda.doc), which allows expansion of the boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Special Announcements…

• August teleconferences.

Join ISMP for our August 3 teleconference, 2006-2007 JC Update: Requirements Related to Medication Use.  The teleconference will be repeated on August 10.

• Webinar

The Nursing Leadership Congress is sponsoring a free webinar on August 2 entitled, Using Human Centered Design to Improve Patient Safety. The program is intended for senior nursing leaders and explores the nurses’ role in designing safe practices. For details visit: www.nursingleadershipcongress.com/nursingcongress/webinars.asp

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