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The following are excerpts from the newsletter

March 8, 2000

  • A multidisciplinary team is essential to medication error reduction efforts
  • High-dose lorazepam infusion and propylene glycol toxicity
  • Safety Briefs
    • Potential look-alike confusion exists between Novaplus brand atracurium injection, a neuromuscular blocker, and Novaplus diltiazem injection, a calcium channel blocking agent.

      Picture of Novaplus products
    • Abbott Laboratories' metoclopramide injection 10 mg per 2 mL, packaged in 2 mL CARPUJECT boxes, looks similar to Carpuject metoprolol 5 mg/5 mL.

    • ADRENALIN Chloride Solution (epinephrine) for topical application is in danger of being confused with Adrenalin Chloride Solution for hypodermic use.

      Picture of Monarch Adrenalin products
    • The Pharmaceutical Research and Manufacturers Association (PhRMA) has formed a 10-member task force and has identified six issues to explore to help practitioners and patients prevent medication errors.
    • Current instructions for preparing SPORANOX (itraconazole) IV are a bit unusual and can easily result in a dosing error.
    • Drug reference publishers and practitioners are encouraged to use a new ISMP web site service, "Textbook Errata." The site, which can be accessed from the main menu on our home page (, lists corrections when a dosing error or other serious error has been identified in a published article or textbook. Publishers have been encouraged to contact ISMP about textual or content errors so they can be quickly communicated on our web site. All reports of such errors that are sent to the USP-ISMP program automatically will be included.
    • PROCANBID (procainamide extended release) 500 mg twice a day was dispensed when a poorly handwritten order for probenecid 500 mg bid was misread.
    • A bibliography of over 130 articles on medication safety has been added to the list of menu options on our web site ( Specific references are listed for focused areas such as pediatrics, automation, failure mode and effects analysis, research-based medication error rates, educational materials, and general reference articles. We will update the bibliography regularly through ongoing review of the literature and include the most significant scientific (theoretical and empirical) and practice-related contributions. If you are aware of an important reference that is not listed in the bibliography, please contact us. If possible, fax the article or abstract to 215 914 1492.
    • Caution: By coincidence, a lot number reading "8 KCL" appears in red, bolded, upper case characters on the reverse side of the unit dose foil package of MYCELEX TROCHE (clotrimazole) 10 mg. The product is manufactured by Bayer Corporation but distributed by Alza Pharmaceuticals. On a line below "8 KCL" the characters "E 1101" also appear. We've notified the manufacturer.

      Mycelex Troche packaging

March 22, 2000

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