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THE FOLLOWING ARE EXCERPTS FROM OUR NEWSLETTER

June 14, 2007

 

Handwritten order for Prandin was misread as Avandia. 

  • A risk that should not be tolerated.

A patient in an emergency room arrested and was unable to be resuscitated after accidentally receiving potassium chloride concentration injection instead of a furosemide injection for diuresis. A nurse was directed to enter the pharmacy after hours for the furosemide injection, but selected the potassium chloride in error. 

  • IV tubing misconnected to tracheostomy collar.

A patient’s IV tubing was accidentally connected to the Luer connection on his tracheostomy collar. Fluid further inflated the tracheostomy collar balloon, causing an airway obstruction. The patient became cyanotic, but the error was quickly noticed and the IV line was disconnected from the tracheostomy collar. 
Special Announcements…

  • Nominations for ISMP CHEERS Awards

Nominations are being accepted for the 9th Annual ISMP Cheers Awards. Self nominations are encouraged. For more information. Click here for more information.

  • AHRQ Osteoarthritis guides

AHRQ has published two new guides, that summarize the benefits and risks of arthritis pain medications. The clinician’s guide, Choosing Non-Opioid Analgesics for Osteoarthritis, evaluates the scientific evidence that applies to the drugs’ benefits and risks; the consumer’s guide, Choosing Pain Medication for Osteoarthritis, summarizes the evidence on prescription and nonprescription drugs. Both can be found at: http://effectivehealthcare.ahrq.gov/reports/index.cfm.

  • Teleconference

Please join ISMP our next teleconference entitled, The Joint Commission (TJC) Update: 2007-2008 Requirements Related to Medication Use, to be held on July 18, and  repeated on August 2. Guest speaker Darryl Rich, PharmD, a surveyor for TJC, will present information regarding the Medication Management (MM) standards (including MM.4.10, regarding review of orders in the emergency department) and the 2008 National Patient Safety Goals (NPSG). In addition, current MM standards and NPSGs that have proven difficult for hospitals during 2006 and 2007 will be discussed, along with strategies for improved compliance. For more information, please visit: www.ismp.org/educational/teleconferences.asp.

  • Employment Opportunities

NURSE: ISMP is seeking a full-time RN with at least 7 years combined clinical and managerial experience, to support its consulting group. Enjoy high job satisfaction as a medication safety expert, while providing support to healthcare professionals and leaders. Applicant must relocate to the Huntingdon Valley, PA, area (Philadelphia suburb) and be able to travel with our consulting team. BSN required; Masters degree and risk management or patient safety experience preferred. Send your resume by fax (215-914-1492) or email (ismpinfo@ismp.org) to Susan Paparella. For more information, visit: www.ismp.org/jobline/joblist.asp?jobType=I.

PHARMACIST: Med-E.R.R.S., a subsidiary of ISMP that performs medical product labeling, packaging, and trademark testing, is seeking a full-time, experienced pharmacist to fill a position as a Medication Safety Analyst. This person will work on medication safety-related projects for pharmaceutical and healthcare industry clients. The position requires at least 5 years experience and excellent clinical, drug information, writing, communication, and interpersonal skills. Pharmaceutical industry experience is a plus. Email (info@med-errs.com) or fax (215-914-1492) or your resume to Susan Proulx.

June 28, 2007


  • Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!
  • Anonymous patches
  • Practitioners have reported that CATAPRES (clonidine) patches present problems because the manufacturer does not print the name of the drug or the strength on the patch itself.

  • New recommendations for the disposal of drugs
  • The Federal government issued guidelines earlier this year calling for certain drugs where diversion or patient safety is of concern to be flushed down the toilet for disposal.

Special Announcements…

  • ISMP-USP workshops
  • ISMP and USP will be offering a workshop this Fall on collecting, analyzing, and prioritizing adverse drug event data. The full-day program, UsingData Effectively to Manage the Risks toMedication Safety, will be held in various cities, including Tampa, Chicago, Rockville, and Las Vegas, from September to December 2007. Participants will learn how to select effective risk reduction strategies based on proven medication safety principles, and the best way to report findings in an actionable format to demonstrate improvement. Breakout sessions will offer participants an opportunity to gain hands-on practice working with safety data. For details, visit: www.ismp.org/educational/ismpuspworkshops.asp.

  • Teleconference
  • Please join ISMP our next teleconference entitled, The Joint Commission (TJC) Update: 2007-2008 Requirements Related to Medication Use, to be held on July 18, and repeated on August 2. Guest speaker Darryl Rich, PharmD, a surveyor for TJC, will present information regarding the Medication Management (MM) standards (including MM.4.10, regarding review of orders in the emergency department) and the 2008 National Patient Safety Goals (NPSG). In addition, current MM standards and NPSGs that have proven difficult for hospitals during 2006 and 2007 will be discussed, along with strategies for improved compliance. For more information, please visit: www.ismp.org/educational/teleconferences.asp.

  • Nominations for ISMP CHEERS Awards
  • Nominations are being accepted for the 9th Annual ISMP Cheers Awards. Self nominations are encouraged.  Click here for more information.

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