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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

may 7, 2009

  • QuarterWatch™ (3rd quarter 2008) Safety concerns with generics, Chantix aggressive behavior, and more
  • Safety Brief: Pump color-code issue.

    The CADD-Solis Ambulatory Infusion Pump is a portable smart infusion pump that allows hospitals to customize various pain management protocols. Clinicians can recognize which protocol is being used because the pump uses color-coding for the graphic display screens. Unfortunately, this could lead to a situation where a nurse “floating” from one CADD-Solis hospital might confuse a color-code when working at a different hospital that uses these pumps.
  • Safety Brief: Old strength Fer-In-Sol out there.

    Carefully examine all oral liquid iron supplement drops, especially Mead Johnson Nutritionals’ Enfamil FER-IN-SOL (ferrous sulfate drops), whether already in stock or received from wholesalers or other sources in new shipments. Fer-In-Sol produced during and prior to the first quarter of 2008 has a concentration of 15 mg elemental iron/0.6 mL.
    However, Fer-In-Sol produced during and after the second quarter of 2008, has a concentration of 15 mg elemental iron/mL. Both strengths also have the same NDC number. One hospital pharmacy told us they had already received the new product with the more dilute concentration and had made the change in their computer system. However, a new shipment arrived from their wholesaler in the old concentration, and they almost dispensed it with the directions for the new formulation.
 Special Announcements
  • Unique 2-day program. Attend ISMP’s Medication Safety INTENSIVE workshop, a one-of-a-kind, interactive program that will teach you how to approach medication safety “through the eyes of ISMP.” The first workshop received rave reviews! It will be held in two more locations during 2009. For details, visit: www.ismp.org/educational/MSI/default.asp.

  • ISMP teleconferences. On May 18, 2009, we will be presenting Pediatric Medication Safety: High- Leverage Strategies for a High-Risk Patient Population. During this teleconference, you will learn why pediatric patients are at high risk for medication errors and strategies to decrease that risk. Some of the topics that will be covered include pediatric adaptation of bar-coding technology, tips on compounding pediatric solutions, issues with standardized doses, and the use of resuscitation cards. On May 28, 2009, we will be presenting Images of Medication Safety in the Radiology Suite: Reducing Error Risk. In this teleconference, we will discuss why medication errors are likely to occur in radiology, the types of errors most commonly seen, and the safe practice strategies that need to be implemented to mitigate risk and ensure patient safety.  For more information and to register for the teleconferences, visit: www.ismp.org/educational/teleconferences.asp.

  • ISMP’s new Practitioner in Residence Program. This comprehensive 1-week “rotation” held at ISMP’s office in suburban Philadelphia is designed to assist healthcare professionals who hold or plan to hold medication/patient safety positions in their organization and want to rapidly advance their safety leadership skills. Participants will work closely with ISMP experts on an individual project while completing medication safety learning modules tailored to their educational needs. For information, visit: www.ismp.org/Consult/practitioner.asp.


may 21, 2009

  • Survey on LASA drug name pairs:
    Who knows what's on your list and the best ways to prevent mix-ups?
  • Safety Brief: On-Q pump issue.

    The elastomeric On-Q pump is a device used after certain surgical procedures to slowly infuse local anesthetics into the incision area for pain control over a prolonged period (see Figure 1). Use of this device has been associated with chondrolysis—destruction of articular cartilage—which occurs most often in shoulders. On-Q pump infusions should never be placed directly into the shoulder joint; if used for shoulder surgery, placement should be external to the joint cavity. For more information check out the newsletter and the manufacturers recommendations.
  • Safety Brief: Problems with barcodes.
    Please let us know if you identify problems with a company’s unit dose package barcode. If you send barcode problems to us along with a publishable photo, it will help us remind companies about the need for adequate quality control.
  • Safety Brief: Heparin cases not quality issue.
    FDA and Baxter reported that a heparin quality issue was not behind the widely publicized DE cases where three patients developed cerebral bleeding after receiving Baxter premixed heparin. The events appear to be related to “underlying medical conditions and risk factors that increase the relative risks involved in using a particular drug.”
  • Safety Brief: Fluorouracil antidote on the horizon?
    Emergency use of an investigational drug, vistonuridine, is showing promise for reducing potentially fatal side effects of fluorouracil overdose. There is currently no antidote for fluorouracil overdose. To learn more, check out the newsletter.
  • Safety Brief: CE on insulin errors.
    A MedScape continuing education (CE) article authored by ISMP nurse Hedy Cohen et al. was posted last week. Avoiding Errors Associated with Insulin Therapy provides free CE credits for physicians, nurses, and pharmacists who complete the program, which can be accessed at: http://cme.medscape.com/viewarticle/702444.
 Special Announcements
  • Unique 2-day program. Attend ISMP’s Medication Safety INTENSIVE workshop, a one-of-a-kind, interactive program that will teach you how to approach medication safety “through the eyes of ISMP.” The first workshop received rave reviews! It will be held in two more locations during 2009. For details, visit: www.ismp.org/educational/MSI/default.asp.

  • ISMP teleconference. Join us on June 11 for our teleconference, Patient Falls and Medication Use: Making the Safety Connection. Our speakers will be discussing: 1) the link between certain classes of medications and the risk of patient falls, 2) pharmacist and nurse interventions that can proactively reduce these risks, and 3) outcomes in their organizations related to implementing these interventions. To register, please visit: www.ismp.org/educational/teleconferences.asp.
  • ISMP’s Practitioner in Residence Program. This comprehensive 1-week “rotation” held at ISMP’s office in suburban Philadelphia is designed to assist healthcare professionals who hold or plan to hold medication/patient safety positions in their organization and want to rapidly advance their safety leadership skills. Participants will work closely with ISMP experts on an individual project while completing medication safety learning modules tailored to their educational needs. For information, visit: www.ismp.org/Consult/practitioner.asp.

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