The following are excerpts from the newsletter
- Nix the quick fix: Drug protocols
- The dawn of the HIPAA privacy rule should not leave
healthcare providers in the dark - The Health Insurance
Portability and Accountability Act (HIPAA) privacy rule
took effect on April 14. One particularly troubling area
of confusion is whether listing the drug's intended purpose
on a prescription violates HIPAA.
- Safety Briefs
- Hazard Alert!
- Confusion between tetanusdiphtheria toxoid (Td) and
tuberculin purified protein derivative (PPD) led to unnecessary
- Precisely wrong - The order below illustrates
what can happen when healthcare professionals pay attention
to exact dosing without considering how the order appears
- Worth Repeating... Again! - Last week, New Jersey
news media revealed another vincristine fatality when
a radiologist gave the patient vincristine intrathecally
instead of cytarabine after performing a lumbar puncture.
- The default code for route of administration led to
an error. A pharmacy order entry system used a common
drug information database, which assigned "IJ"
as the default route code for all "injectable"
- Message in our mailbox: After reading the article
on epinephrine - ephedrine mix-ups ("Looks"
like a problem: ephedrine - epinephrine. ISMP Medication Safety Alert!April 17, 2003), Stein Lyftingsmo from Hospital
Pharmacy of Elverum, Norway, reminded us that adrenaline
is the approved name for epinephrine in Great Britain.
- Gear up for the 2004 Joint Commission Medication
Management Standards - Learn first-hand about the
new JC Medication Management standards and the novel
approach to the survey process beginning in 2004 from
Darryl S. Rich, PharmD, MBA, Associate Director, Survey
Management and Development for the Joint Commission. On
July 1 and July 8, 2003, ISMP will host a two-part teleconference
on these topics, with ample time to answer your questions.
Dr. Rich receives and answers scores of questions each
month about standards interpretation, and authors a column
on Joint Commission issues in Hospital Pharmacy. You can't
go wrong by learning about the standards and survey process
from one of the most knowledgeable sources on the topic!
We'll have more details about the teleconferences in our
next newsletter, but for now, reserve the dates.
Oral vancomycin does not treat systemic
infections - Over the years, we've heard of patients
who were treated with IV vancomycin for systemic infections
and then erroneously discharged on the oral form, and
we continue to receive such reports.
A more flexible daily dose regimen
for LANTUS insulin glargine could increase confusion
Learn about how one hospital's use
of clever label design has led to safer medication
Investigation of naloxone use uncovered
an error in converting oral hydromorphone to the IV
Learn about an error that occurred
because the pharmacy computer had no dose limits for
- Special Announcements
- Public workshop on premarket drug name safety testing
- On June 26, 2003, FDA, ISMP and the Pharmaceutical
Research and Manufacturers of America (PhRMA) will be
co-sponsoring a public workshop entitled "Drug
Naming Approaches - Improving Patient Care by Reducing
- ISMP teleconferences
on new Joint Commission standards - On July 1 and 8,
2003, ISMP will host a two-part teleconference series
on the Joint Commission's 2004 Medication Management
Standards, the new approach to the accreditation process,
and an update on the National Patient Safety Goals.
- Worth Repeating - Tragedies involving chloral hydrate
use in the pediatric population continue to be reported.
- Message in our mailbox - Marva Tschampel and Mary
Beth Shirk, pharmacists at Ohio State University Hospital
in Columbus, wrote to warn against "on demand"
dispensing of medications based solely on requests for "missing