ISMP Medication Safety Alert! Acute Care Edition

Measuring up to medication safety
GLUCAGEN (glucagon) bar-coding problem could lead to administration of diluent instead of active drug.
Watch for potential mix-ups with new paclitaxel formulation, ABRAXANE (paclitaxel protein-bound particles for injectable suspension). Mistaking the new formulation for traditional drug could lead to overdose.
Look-alike packaging warning: Baxter's atropine 0.4 mg/mL and adenosine 6 mg/2 mL can easily be confused.
Worth Repeating: labeling medications on the sterile field is essential for patient safety.
Methotrexate calculation error highlights the value of independent double checks.

March 24, 2005

Medication orders: Don't put me on hold
Merck to make improvements to unit dose packaging to prevent errors.
Confusion between Canadian and us drug name leads to administration of PROAMATINE (midodrine) instead of NAMENDA (memantine).
HECTOROL (doxercalciferol) labeling includes dangerous dose designations.
ISMP supports use of Brosleow tape.
Be wary of confusion between HBIG (hepatitis B immune globulin) and BABYBIG (botulism immune globulin intravenous).
Sterile Cockpit - prevent errors due to distractions by providing healthcare practitioners a 'sterile cockpit' for critical phases of medication use.
Reports submitted to ISMP help influence labeling change for 2 mg/mL hydromorphone vials by Mayne Pharma.

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