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The following are excerpts from the newsletter

May 2, 2001

  • Please don't sleep through this wake-up call! - including a table of dangerous abbreviations and dose expressions most often associated with misinterpretation and patient harm (as reported to the USP-ISMP Medication Errors Reporting Program).
  • Safety Briefs
    • Orders for COLAZAL (balsalazide), a drug used to treat mild to moderate ulcerative colitis, could easily be confused with the antipsychotic CLOZARIL (clozapine).
    • The World Health Organization, the International Union Against Tuberculosis and Lung Disease, and the Centers for Disease Control, recommend the use of RIFAMATE (300 mg rifampin and 150 mg isoniazid) for the treatment of tuberculosis. Rifamate is very similar to the name rifampin. Consequently, mistakes have been made and patients have been given rifampin when Rifamate was ordered.
    • The US Senate Health, Education, Labor & Pensions Committee will hold hearings on May 24 to discuss patient safety issues including new bipartisan legislation to promote voluntary reporting and quality improvement.

May 16, 2001

  • Savings offset costs associated with CPOE: Can you afford to omit it in future strategic plans?
  • Common floor stock bowel prep drugs may pose problems in renal patients.
  • Safety Briefs
    • Confusion between glass bottles of premixed nitroglycerin and D5W
    • The FDA issued a public advisory about significant updates to the labeling of Sporanox (itraconazole) and Lamisil (terbinafine HCL) due to small risk of developing congestive heart failure and serious liver problems.
    • Oklahoma State Board of Health has granted legal protection to USP Medication Error Reporting Programs, including MedMarx and USP Medication errors Reporting Program (operated in cooperation with ISMP).
    • ISMP honored with this year's Paul G. Rogers National Council on Patient Information and Education (NCPIE) Medication Communicator Award.

May 30, 2001

  • New official interpretation of JC standard bans open access to pharmacy after hours
  • Safety Briefs
    • A physician selected OCCLUSAL-HP (17% salicylic acid for wart removal) instead of OCUFLOX (ophthalmic ofloxacin, an antibiotic) from a alphabetical product list in a computerized prescriber order entry system. A pharmacist recognized the near disaster during patient counseling.
    • Were you aware that certain eye lubricants and other common medications or topical agents can catch fire during surgical procedures that involve heat? This safety brief provides critical information about surgical fires.
    • The Institute for Healthcare Improvement (; 617 754 4800) is conducting a 12-month long breakthrough series, Quantum Leaps in Patient Safety - Redesigning Culture and Processes of the Medication System. The first learning session will be held on June 25-26, 2001, in Atlanta, GA.
    • Have you seen or used the new ANZEMET (dolasetron mesylate) injection ampuls yet? The new label is very difficult to read and the ampul itself easily fractures if it isn't opened exactly as instrutced by the manufacturer. More.
      Figure 1. New (left) and old Anzemet ampuls as pictured in recent mailing from Aventis.

      Also, the glass ampul itself has gone from fully scored (easily opened) to a "One Point Cut," which fractures if it isn't opened precisely as instructed.

    • Acetylcysteine oral solution may be prone to accidental IV administration. Learn what the manufacturer is doing about the situation.
    • Staff changes at ISMP: Karen Z. Bakst, RPh and Nancy J. Globus, PharmD have joined the staff as medication safety analysts in our Med-E.R.R.S. Division. Matthew P. Fricker, RPh, MS, has joined ISMP to manage our specialty consulting operations. Matthew Grissinger, RPh, our current Safe Medication Management Fellow, will remain with ISMP after completion of the program and he will also work in the Med-E.R.R.S.

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