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 Assessment^TM. 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

• Want a savvy participant in your error-prevention program? Put a consumer on your team
• Technology - only as good as the user!
• Safety Briefs
  • Some healthcare workers have been confusing the two commercially available anti-thymocyte globulin products. Both are antibodies raised in animals, which act against lymphocytes and T-cells to suppress cell-mediated immunity. Orders stating only "anti-thymocyte globulin" or "ATG" must be clarified.
  • No accidents have been reported yet, but Faulding's vincristine sulfate and vinblastine sulfate products look dangerously similar.
    
    Picture of Faulding packages for Vincristine and Vinblastine
  • An order received by a pharmacist for REMICADE (infliximab) was profiled and prepared as RITUXAN (rituximab).
  • Please join us at the ASHP Annual Meeting in Philadelphia to discover new horizons in technology. On Monday, June 5, 2000, 11:30 a.m. to 1:45 p.m., we will be presenting " Technological Advances in Medication Management," sponsored by Becton-Dickinson. On Tuesday, June 6, 2000, from 11:30 a.m. to 1:45 p.m., we will be presenting "Closing the Patient Safety Loop: Technology Update," sponsored by Autros Healthcare Solutions. Each sponsor is working hard to help us improve safety through the innovative use of advanced technology. Both exhibitor's theaters will be held in room 202 at the Pennsylvania Convention Center. Preregistration is not required, but seating is limited.
  • A California hospital received media attention this week for providing medical staff with a handwriting improvement course as a way to prevent medication errors.
  • There U go again: The abbreviation "IU" (international units) in an order for "Vitamin E 100 IU daily" was misinterpreted as IV (intravenous). This led to drawing capsule contents into a syringe for intravenous administration.
  • A complete set of back issues of the ISMP Medication Safety Alert! (from January, 1996) is available on CD-ROM. The material is presented in Adobe PDF format with the Adobe Acrobat Reader included. All articles are searchable in full text and may be copied for internal use. Visit our web site or call us to place an order. Purchase orders and major credit cards are accepted.

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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