June 4, 2009

• Icons and symbols on IV related products: Global industry must reflect on the safety aspects.
• Purple is not an official standard for either enteral feeding equipment or PICC lines.
  
  An epileptic patient who was supposed to receive oral KEPPRA (levetiracetam) liquid via a PEG tube instead received it IV via a Bard PowerPICC (peripherally inserted central catheter) line. An oral Baxa amber syringe that held the levetiracetam did not connect properly to the hub of the PICC line, however it could be held easily against the opening for the injection. It’s possible that the experienced nurse who incorrectly gave the drug IV was confused by a purple color system available from Covidien for enteral feeding equipment. The color is identical to the purple coloring used for the patient’s Bard PowerPICC line. Learn more about preventing errors like this in your facility in the newsletter.
  
• True allergy or other symptom?
  
  Most of us realize that documenting patient medication allergies without including the type of reaction could lead to unnecessarily withholding the medication to which the patient has actually experienced a non-life-threatening drug reaction, not allergy. In one reported case, an elderly patient taking carbamazepine was given Darvocet-N postoperatively because in the patient’s chart was a notation that he was “allergic” to codeine, when it really just made him sleepy. The patient died from carbamazepine poisoning believed to be due to a drug-drug interaction with the Darvocet-N. Has allergy documentation been a topic at your medication safety committee meeting?
  
• Safety Brief: Too much HYDROmorphone.
  
  A 40-year-old, healthy man visited a hospital emergency department for severe throat pain. He suffered respiratory distress after three doses of HYDROmorphone 2 mg IV, and eventually died. How could this tragic event have been prevented? Read more in the newsletter.
  
• Safety Brief: Patient safety increased in obstetrics.
  
  A study published in the May issue of American Journal of Obstetrics and Gynecology indicates that a safety nurse position, created to oversee a comprehensive patient safety program, helped cut adverse obstetrical outcomes by 40%. For more information, check out an AMA News article about the published study (www.amaassn.org/amednews/2009/05/18/prsb0518.htm)
  
• Safety Brief: Medication patch slips into wrong pocket.
  
  In the process of withdrawing a patient’s nicotine patch from an automated dispensing cabinet (ADC), a carousel pocket opened to reveal two nicotine patches and one fentaNYL 50 mcg/hour patch. This wasn’t due to a stocking error, rather the fentaNYL patch “slipped” over the top of one pocket and into another pocket that contained nicotine patches. If you use an ADC, verify the medications stored in the carousel have enough room. What solution did this hospital institute? Check out the newsletter for more detail. 
  
• Safety Brief: Volume control set safety.
  
  Hospitals that still use BURETROL or SOLUSET volume control sets (VCS) should examine how they are being used to deliver IV medications in patient care units, including the emergency department. Of concern is the lack of identifying the drug placed in the VCS—particularly in an emergency—as well as the potential for chemical inactivation or precipitation that may occur in the VCS or IV tubing when multiple medications are administered using the same set. If VCS are used, ensure that staff label the chamber when medications are added, check incompatibilities with pharmacy before adding the drug, and maintain sterile technique.
  
• Safety Brief: Free medication 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!

• ISMP teleconference. Join us on June 11 for our teleconference, Patient Falls and Medication Use: Making the Safety Connection. Our speakers will be discussing: 1) the link between certain classes of medications and the risk of patient falls, 2) pharmacist and nurse interventions that can proactively reduce these risks, and 3) outcomes in their organizations related to implementing these interventions. To register, 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.

june 18, 2009

• Intrathecal injection warrants mask worn by clinician during procedure
• ISMP launches first self assessment of ADC safety
  
  ISMP has introduced the first Medication Safety Self Assessment for Automated Dispensing Cabinets. The assessment contains 12 core elements that support the safe use of ADCs, which are based on guidelines developed by a national forum convened by ISMP, comprising practitioners and vendors with expertise in the safe use of ADCs. The assessment and directions for how to use it to evaluate your facility practices are available at: www.ismp.org/selfassessments/ADC/survey.pdf
  
• Safety Brief: Green caps on generic methylergonovine cause concern.
  
  A newly approved generic methylergonovine maleate, packaged in a vial, is available from PharmaForce, Inc. Some hospitals have been using these instead of METHERGINE (methylergonovine maleate), which is packaged in ampuls and overwrapped in amber plastic. Unfortunately, the 1 mL vial plastic caps are green and the very same shade as well-established PITOCIN (oxytocin) vials, available from JHP Pharma. Depending on how the vials are stored, their caps and similar size make them appear quite similar. Is this a risk at your facility? Check out the newsletter for ways to prevent potentially devastating mix-ups.
  
• Safety Brief: Should Zosyn be available in ADC stock?
  
  One facility recently decided to begin storing Zosyn in the Emergency Department (ED) ADC. To help avoid potential problems, the ADC was programmed to query about penicillin allergies before the drug could be removed. However, this did not prevent the administration of Zosyn to a penicillin allergic patient within just a few weeks of stocking the drug. How do you manage this risk? Check out the newsletter for some ideas.
  
• Safety Brief: Help needed with product safety testing.
  
  If you are a pharmacist, nurse, unit clerk, pharmacy technician, or other healthcare practitioner who is interested in furthering medication safety, you can make a difference! Med-ERRS (a subsidiary of ISMP) is looking for assistance to help evaluate medication labels, drug packaging, and proposed drug names prior to submission by pharmaceutical and biotech companies for approval by FDA. The process is simple and fun, and a small honorarium is paid. For more information or to sign up, go to: www.mederrs.com, and click on Become a Reviewer.

• ISMP teleconferences. July 23: Reducing the Risk of Patient Harm from Chemotherapeutic Agents We have lined up one of the most knowledgeable speakers on chemotherapy safety,Sylvia Bartel, RPh, MPH, from Dana-Farber Cancer Institute, to discuss preventable adverse drug events with chemotherapy, their causes, and best practices that can 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. As in the past, our speaker, Darryl Rich, PharmD, a surveyor for TJC, will provide you with insightful tips to help meet the intent of the standards and goals. For details on both programs, 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!