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July 12, 2007

• Requirement #1–Patch should stick to the patient!
• Warning! Exactacain straw must fit spray release button.

A safety risk that involves Exactacain applicator straws “popping off into patients’ throats” has been reported. Product changes to the Exactacain spray release button are at the root of the problem, but clinicians can take corrective action. 

• New ceftriaxone warning.
  
  

The FDA and Roche published new information about a potential problem when ROCEPHIN (eftriaxone) is used concomitantly with calcium or calcium-containing products.  Clinicians who care for neonates should be especially aware of the new warnings.

• ISMP Quarterly Action Agenda

Special Announcements…

• Joint Commission Update

It’s not too late to register for our teleconference, Joint Commission Update: 2007-2008 Requirements Related to Medication Use, to be held on July 18, and repeated on August 2. Please visit www.ismp.org/educational/teleconferences.aspfor details about the 2008 safety goals and standards that will be discussed.

• Employment opportunity.
  
  
ISMP is seeking a full-time RN with clinical and managerial experience to support its consulting group.  For details, visit: www.ismp.org/jobline/joblist.asp?jobType=I.

July 26, 2007

• Failure to cap IV tubing and disinfect IV ports place patients at risk for infections
• Numerous problematic name pairs relegated to history.

Reliant Pharmaceuticals is poised to announce that OMACOR, used in the treatment of hypertriglyceridemia, will soon undergo a name change to LOVAZA.  This action is being undertaken to reduce mix-ups between Omicor and AMICAR, an antifibrinolytic agent.  Read on to learn more about problematic name pairs that resolved following name changes.

• Insulin CONCENTRATE U-500.
  
  

  ISMP continues to receive reports of errors involving orders for regular insulin U-500 instead of U-100.  In light of rising use of U-500 insulin products in acute care settings, measures to prevent prescribing and dispensing errors should be undertaken.

• WHO: Dilute vincristine in a minibag.

Last week the World Health Organization published a drug alert about vincristine following the death of a 21-year-old woman in Hong Kong.  WHO called for dilution of the drug in a minibag and said not to dispense it in a syringe, recommendations consistent with those made by ISMP.

World Health Organization: Information Exchange System - Alert No. 115, Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag

• Using PDAs to reduce errors.
  
  A study of nursing students who used personal digital assistants (PDAs) showed that PDAs have the potential to reduce medication errors and improve efficiency.

Special Announcements…

• Hydromorphone survey.

FDA is working with ISMP to reduce the risk of drug-name mix-ups between morphine and hydromorphone, including the possibility of establishing a consistent way to present hydromorphone using tall man letters.  Take our quick survey at: www.ismp.org/survey/tallman.asp by August 10, 2007.

• ISMP teleconference.
  
  
Please join us for our next teleconference, Reducing the Risk of Patient Harm with Anticoagulant Therapy, to be held on September 19, 2007, from 1:30 to 3:00 p.m. ET.  With a special focus on heparin and warfarin, this teleconference will provide you with the building blocks necessary to define and implement an anticoagulant management program, as required by a 2008 Joint Commission National Patient Safety Goal.  Visit www.ismp.org/educational/teleconferences.asp for details.

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