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The following are excerpts from the newsletter

May 3, 2000

  • Shedding "lyte" on the multifaceted nature of errors
  • In the mail: ISMP Medication Safety Self AssessmentTM. Make a difference - participate!
  • Safety Briefs
    • Concerns raised about the use of the name ZYVOX and possible confusion.
    • Problematic brand name, FIV-ASA (mesalamine) may cause confusion.
    • Poor handwriting of ACIPHEX caused confusion with ACCUPRIL in recent report.
    • FDA has approved LANTUS (insulin glargine [rDNA origin]). Concern is mounting that oral or written orders for Lantus may be mistaken as "Lente".
    • The European Committee for Standardization issued a report about the dangers of incorrect newsletters/acutecare/articles between devices used for the vascular, enteral, respiratory, and other body systems.
    • Hospitals sometimes struggle over the meaning of the word "midnight."
    • We say we get it, but do we really? Is it really non-punitive?

May 17, 2000

May 31, 2000

  • Mandatory reporting programs: Why we can't "look the other way"
  • Design flaw predisposes Abbott Lifecare PCA Plus II pump to dangerous medication errors.
    On Sunday, the Tallahassee Democrat (FL) reported that a 19-year-old mother died hours after a routine cesarean section when a nurse accidentally misprogrammed an Abbott Lifecare PCA Plus II Infusion pump.
  • Safety Briefs
    • A hospital recently reported two medication errors where orders for "folinic acid" were confused with folic acid.
    • New drug information database available for Palm based PDA's at www.ePocrates.com is available free. The application, known as ePocrates qRx, makes important clinical information for most medications immediately available to clinicians when it's needed.
    • Gliatech, Inc. recently announced the initiation of Phase II clinical trials for a new compound that will be used to treat patients with attention deficit hyperactivity disorder (ADHD). The currently proposed name may lead to confusion. The company intends to sell the product to a larger pharmaceutical company and anticipates a name change.
    • The American Society of Healthcare Risk Management is sponsoring the first-ever National Healthcare Risk Management Week on June 19-26, 2000.
    • State Senate bill 2187, recently introduced in Massachusetts, proposes the creation of the "Betsy Lehman Center for Patient Safety and Medical Error Reduction."

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