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THE FOLLOWING ARE EXCERPTS FROM OUR NEWSLETTER

July 2, 2009

  • Misidentification of alphanumeric symbols in both handwritten and computer-generated information
  • Safety Brief: Med list filing error.
    A hospital reported an incident in which a patient’s medication list was attached to the wrong patient’s record in the emergency department (ED). The error went undetected for several hours and could have led to serious harm. It was discovered that the way ED charts were paper-clipped and filed that this was a common occurrence. For suggestions to prevent misfiling at your facility, see this edition of the newsletter.  
  • Safety Brief: ADC webcast access.
    Improving the Safety of Medication Administration: A Focus on Nursing Best Practices Using Automated Dispensing Cabinets, is the title of a recently recorded webcast available on Cardinal Health’s Center for Safety and Clinical Excellence website (http://attewc.webex.com/attewc/onstage/tool/record/viewrecording1.php?EventID=558706088). The program, presented in part by ISMP’s Michelle Mandrack and Michael Cohen, includes a discussion about common sources of errors and gives tips on maximizing the safe use of ADCs. A great companion tool to the webcast is ISMP’s newly developed Medication Safety Self Assessment for Automated Dispensing Cabinets, available at www.ismp.org/selfassessments/ADC/Survey.pdf.
Special Announcements
  • ISMP teleconferences. July 23: Reducing the Risk of Patient Harm from Chemotherapeutic Agents. Sylvia Bartel, RPh, MPH, from Dana-Farber Cancer Institute, will discuss preventableadverse drug events with chemotherapy, their causes, and best practices to improve safety.
  • August 13: The Joint Commission Medication Management Update 2009. Back by popular demand, we will again present our annual update on The Joint Commission (TJC) standards and National Patient Safety Goals related to medication use. For details on both teleconferences, please visit: www.ismp.org/educational/teleconferences.asp.

  • ISMP’s Practitioner in Residence Program. This comprehensive 1-week “rotation” held at ISMP’s office in suburban Philadelphia is designed to assist healthcare professionals who hold or plan to hold medication/patient safety positions in their organization and want to rapidly advance their safety leadership skills. Participants will work closely with ISMP experts on an individual project while completing medication safety learning modules tailored to their educational needs. For information, visit: www.ismp.org/Consult/practitioner.asp.
  • Free Safety Videos. The latest medication related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp). Check them out!

July 16, 2009

  • Process for handling elastomeric pain relief balls (ON-Q PainBuster and others) requires safety improvements
  • Safety Brief: Smoking cessation drug update.

    The FDA has issued a public health advisory (http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm169988.htm) stating that the manufacturers of the smoking cessation aids varenicline (CHANTIX) and buPROPion (ZYBAN and generics) are to add new boxed warnings emphasizing the risk for serious neuropsychiatric symptoms associated with these medications.  For a link to the new varenicline (CHANTIX) label, check out the newsletter.

  • Safety Brief: Scannability resource.

    The Veterans Health Administration Office of Health Information Bar Code Resource Office has agreed, at the request of ISMP, to alert us regarding issues with medication barcodes that are identified through their barcode verification process.  Read more about problems identified by their office in the newsletter.

  • Safety Brief: Insulin errors.

    Recently, a renal transplant recipient developed cardiopulmonary instability after receiving insulin as a part of the treatment regimen for hyperkalemia.  While searching for the cause, a physician discovered that the patient accidentally received 100 units instead of 10 units of regular IV insulin.  It was later determined during the root-cause analysis that an anesthesiology resident had prepared the insulin incorrectly, and that training of the anesthesiology residents in medication preparation was inadequate.  Check out the newsletter to read more about this event and what is being done to prevent similar errors from occurring.

  • Message in our mailbox:

    Craig M. Martin, MD, FACO, offers another explanation for how obstetrical patients developed bacterial meningitis following intrathecal injections of anesthetics in response to a recent article (http://www.ismp.org/Newsletters/acutecare/articles/20090618.asp).  In that article, we noted that the health department had contributed the cause of the events to an anesthesiologist not wearing a mask during the procedures.  Check out the newsletter to read about Dr. Martin’s explanation.

  • Your Reports at Work:

    Brookstone Pharmaceuticals has voluntarily recalled all lots of Concentrated Acetaminophen Drops in 16 ounce (473 mL) bulk containers (www.fda.gov/Safety/Recalls/ucm171780.htm). ISMP reported about the potential errors associated with this product in the June 2008 ISMP Hazard Alert (www.ismp.org/Newsletters/acutecare/articles/20080605_1.asp).
 Special Announcements
  • ISMP Survey: What’s a near miss? We’re interested in knowing how you define the term near miss in the context of medication-related conditions and/or events.  Please take this opportunity to click here (www.ismp.org/survey/Survey200907.asp) to enter your response before August 28!
  • ISMP Cheers Awards!  We are accepting nominations for this year’s ISMP Cheers Awards through August 27, 2009. The Cheers Awards honor individuals, organizations, companies, and agencies that have made excellent advances in medication safety in the past year.  For more information or to submit a nomination, please visit: www.ismp.org/Cheers.

  • ISMP teleconferences. July 23: Reducing the Risk of Patient Harm from Chemotherapeutic Agents. Sylvia Bartel, RPh, MPH, from Dana-Farber Cancer Institute, will discuss preventable
    adverse drug events with chemotherapy, their causes, and best practices to improve safety.
    August 13: The Joint Commission Medication Management Update 2009. Back by popular demand, we will again present our annual update on The Joint Commission (TJC) standards and National Patient Safety Goals related to medication use. For details on both teleconferences, please visit: www.ismp.org/educational/teleconferences.asp.
  • Free Safety Videos. The latest medication related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp). Check them out!

July 30, 2009

  • How colorful is too colorful when it comes to patient safety? Will color-tinted IV tubing help?
  • Investigate and clarify requests for missing doses

    A physician ordered vitamin K1 (phytonadione) 2 mg IV for a patient with an elevated INR of 3.8.  When the drug did not become available for removal from the automated dispensing cabinet (ADC) within a usual timeframe, the nurse faxed the pharmacy a “missing medication” request, in case pharmacy had overlooked the order.  The nurse misinterpreted the order, however, as vitamin K1 20 mg IV due to a poorly handwritten order by the physician, and wrote the “missing medication” request as such.  The pharmacist recognized the order for vitamin K1 20 mg IV as being too high and clarified the order to the physician-ordered dose of 2 mg prior to dispensing.  Learn more about this error and steps you can take to reduce the risk of this type of error reaching patients in your hospital.
  • Safety Brief: Provera, Prozac, or Proscar?

    An order was written for Provera (medroxyPROGESTERone) 10 mg PO daily; however, the handwritten order was misinterpreted as Prozac (FLUoxetine) 10 mg PO daily.  Check out the newsletter to find out how several other nurses, pharmacists, and physicians interpreted the order.

  • Safety Brief: The lot number is where?

    It was discovered that documentation errors had been occurring at a particular hospital, by more than one nurse, with the lot number and expiration date of PNEUMOVAX 23 (pneumococcal polysaccharide vaccine [polyvalent]).  Read more about what caused the confusion and steps you can take to help reduce similar errors from occurring at your hospital in this issue of the newsletter.

  • Safety Brief: Fatal sound-alike.

    A patient’s physician had called in an order for an ampul of naloxone in order to treat the patient for respiratory depression second to a dose of parenteral morphine that the patient had received.  The nurse who took the phone order, however, heard LANOXIN (digoxin) which the nurse administered.  Learn more about this situation and the contributing factors that resulted in this error in the newsletter.

  • Message in our mailbox: Pharmacy should prepare pain pumps.

    In a response to an article in our previous newsletter on ON-Q elastomeric infusion pumps, Darryl Rich, PharmD of the Joint Commission (TJC), informed us that filling the pumps in the OR often fails to meet TJC standards.  Although many of these pumps are currently being filled in the OR, TJC states that the parenteral solutions in these devices should always be prepared in pharmacy with the exception of urgent situations.  Check out the newsletter to learn about what actions the manufacturer of the ON-Q pump is now taking.

Special Announcements
  • ISMP welcomes Rebecca (Becky) Lamis, PharmD as the ISMP Safe Medication Management Fellow for 2009-2010.  Becky received her PharmD from the University of Iowa, College of Pharmacy, and completed a Pharmacy Practice Residency at Wesley Medical Center in Wichita, KS.  Becky’s fellowship is being supported through a grant from the Cardinal Health Foundation.
  • ISMP welcomes Alice Tu, PharmD, who is the FDA-ISMP Safe Medication Management Fellow.  This is a joint FDA-ISMP fellowship during which Alice will work 6 months at ISMP and 6 months at FDA in the Center for Drug Evaluation an Research, Division of Medication Error Prevention and Analysis.  Alice received her PharmD from the University of North Carolina Eshelman School of Pharmacy in Chapel Hill, NC, and completed a Managed Care Pharmacy Residency at Medco Health Solutions in Franklin Lakes, NJ.
  • ISMP Survey: What’s a near miss? We’re interested in knowing how you define the term near miss in the context of medication-related conditions and/or events.  Please take this opportunity to click here (www.ismp.org/survey/Survey200907.asp) to enter your response before August 28!
  • ISMP Cheers Awards!  We are accepting nominations for this year’s ISMP Cheers Awards through August 27, 2009. The Cheers Awards honor individuals, organizations, companies, and agencies that have made excellent advances in medication safety in the past year.  For more information or to submit a nomination, please visit: www.ismp.org/Cheers.
  • ISMP teleconferences.  August 13: The Joint Commission Medication Management Update 2009. Back by popular demand, we will again present our annual update on The Joint Commission (TJC) standards and National Patient Safety Goals related to medication use. For details on both teleconferences, please visit: www.ismp.org/educational/teleconferences.asp.
  • Free Safety Videos. The latest medication related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp). Check them out!

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