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The following are excerpts from the newsletter


July 1,1998

  • Drug name mix-ups: Much more than look-alike names
  • Invirase® and Fortovase®: Potential confusion between two saquinavir formulations
  • New ISMP fellow named
  • Safety Briefs:
    • National medication error reporting programs reveal that medication errors are repetitive in nature. Yet, far too many organizations and individuals are content to wait until a serious error hits home before they undertake aggressive preventive actions.
    • A pharmacist prepared an epidural PCA with 50 mg of Dilaudid® HP (hydromorphone) from a 5 mL, 10 mg/mL ampul, instead of 500 mcg of fentanyl, from two 5 mL, 50 mcg/mL ampuls. Hydromorphone was incorrectly removed from the pharmacy's own automated dispensing module.
    • Janssen Pharmaceutica mailed a Propulsid® (cisapride) "Dear Dr. Letter" to inform health professionals of labeling changes concerning new contraindications, warnings, precautions, adverse reactions, and drug interactions.
    • In our February 11, 1998 issue, we mentioned reports of mix-ups between premixed heparin IV bags and DuPont Pharma's Hespan® (hetastarch in sodium chloride), packaged in McGaw Excel® bags. Other similar mix-ups are also being reported.
    • Pyxis Corporation has introduced a computerized, inventory exchange system (CUBIE™).

July 15,1998

  • Another ampho-terrible mix-up
  • ISMP Action Agenda: Items from the ISMP Medication Safety Alert!, April - June, 1998
  • Safety Briefs
    • FDA and USP recently received reports noting confusion between Soriatane® (acitretin) capsules and Loxitane® (loxapine succinate) capsules.
    • Neumega® (oprelvekin) is supposed to be diluted with only 1 mL of sterile water for injection before being administered subcutaneously. However, when the product was launched last year, a suitable 1 mL vial was unavailable. For customer convenience, the drug's manufacturer, Genetics Institute, elected to include a 5 mL vial with instructions to use 1 mL. Unfortunately, we've seen some error reports where all 5 mL was used to dilute Neumega - far too much volume for injection.
    • A 13-month study at Albany Medical Center, Albany, New York (Lesar TS. Errors in the use of medication dosage regimens. Arch Pediatr Adolesc Med; 1998;152:340-4), examined the nature of 200 consecutive prescribing errors arising from the use of dosage equations.
    • As far as we can determine, the Florida State Board of Pharmacy is the first state to actually propose that continuous quality improvement (CQI) be incorporated into standards of pharmacy practice to address medication errors.

July 29,1998

  • Another case of name confusion (what else is Neu?)
  • Caution urged to prevent unit dose package mix-ups
  • Legislative alert!
  • Safety Briefs
    • Becton Dickinson recently recalled certain lot numbers of their 1 mL Safety-Lok® insulin syringes
    • Major concerns have been raised about the use of albumin in critically ill patients in British Medical Journal article.
    • Are we meeting your expectations with the ISMP Medication Safety Alert!?
    • Many organizations are developing policies and procedures to specify a plan of action for handling a sentinel event in the wake of the Joint Commission's Sentinel Event Policy.
    • Another episode of confusion between a lipid-based product and its conventional counterpart has occurred. In this case,a physician ordered conventional doxorubicin.
    • An index of 1997 issues of ISMP Medication Safety Alert! is available from ISMP
    • Effective interpersonal communication is a crucial component of medication error preventio

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