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The following are excerpts from the newsletter

may 5, 2011

  • Multiple latent failures align to allow a serious drug interaction to harm a patient
  • Safety Brief: Broselow tape for chemical warfare
    Learn more about which Tape from Broselow can be confused with the already existing Broselow Pediatric Emergency Tape.
  • Safety Brief: Teva’s lansoprazole ODT clogs tubes
    The FDA stated receiving reports of Teva Pharmaceuticals’ lansoprazole orally disintegrating tablet (ODT) clogging and blocking oral syringes and feeding tubes when the drug was administered as a suspension through these devices. Find out more.
  • Safety Brief: Lawyers weigh in on consistent use of smart pump libraries
    We still hear about serious medication errors in which users bypassed pump libraries, resulting in patient injuries. Available smart pump technology should be fully maximized and employed consistently, and alerts issued by the technology should be addressed before administering parenteral therapy. Check out this week’s newsletter to access newly published literature on errors with bypassed smart pumps.
  • Safety Brief: FDA comments on benzocaine risk of methemoglobinemia. On April 7, 2011, FDA reported that the agency continues to receive reports of methemoglobinemia, a serious and potentially fatal adverse effect associated with topical benzocaine products.
  • Safety Brief: Important national survey on USP <797> compliance. Please make sure your pharmacy participates in the largest and most comprehensive study ever undertaken of USP <797> compliance. ISMP endorses the study, which will take 60–90 minutes to complete (in multiple sittings if desired). Please register for the study today at: www.797study.com, using Survey Code A797C.
  • Safety Brief: Report drug shortages. ISMP has partnered with the American Society of Health-System Pharmacists (ASHP) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to explore and communicate drug shortage issues with FDA’s Drug Shortage Program (DSP). You can assist by providing details regarding severe drug shortages directly to the FDA DSP through contacts and links you’ll find on the DSP website at: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm142398.htm

Special Announcements

  • Webinar. On June 29, ISMP will present a webinar, The Overall Impact of Computerized Prescriber Order Entry (CPOE) Implementation on Hospital Medication Systems: Pharmacists Share Their Experiences. Follow the journey as our speakers discuss navigating through transformation of relationships and alterations in workflow and efficiency. The speakers will highlight anticipated benefits and realities before and after the CPOE go-live date. For details, visit: www.ismp.org/educational/webinars.asp.
  • Celebrate Nurses! On May 6-12, ISMP is joining the American Nurses Association in celebrating Nurses Trusted to Care, as part of National Nurses Week. In honor of the dedication, commitment, and tireless effort of the nearly 3.1 million registered nurses nationwide to promote and maintain the health of this nation, the ANA and ISMP are proud to recognize registered nurses everywhere for the quality work they provide 24 hours a day, 7 days a week, 365 days a year.
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication.

may 19, 2011

  • QuarterWatch™: 2010 (Quarter 3)
    New signals for liraglutide, QUEtiapine, and varenicline
  • Final Acute Care Guidelines for Timely Administration of Scheduled Medications posted on ISMP website
  • Safety Brief: ActHIB component of two-vial Pentacel is repeatedly missed
    ISMP continues to receive reports involving infants who must return to their doctor’s office with their parents in order to receive the inadvertently omitted Haemophilus influenzae type b component of PENTACEL.
  • Safety Brief: Teva’s lansoprazole ODT clogs tubes
    The anti-Parkinson’s drug STALEVO (levodopa, carbidopa, and entacapone) is labeled in reference only to the levodopa component which is confusing and error prone. Find out more in this week’s newsletter.
  • Safety Brief: STD CT misread as GC
    A young male patient was mistakenly treated with IM cefTRIAXone (ROCEPHIN) when a treatment record subsequent to sexually transmitted disease (STD) testing appeared to show that the patient had gonorrhea. Learn more.
  • Safety Brief: ADEs in elderly on long-term nitrofurantoin
    A prescriber contacted ISMP through the ISMP Medication Errors Reporting Program asking us to inform others about nitrofurantoin contraindications and the need to monitor patients who are receiving the drug.
  • Safety Brief: FDA consumer materials on OTC analgesics
    FDA launched some new products in support of an ongoing national education campaign to provide consumers with advice on the safe use of over-the-counter (OTC) pain relief products, including acetaminophen and nonsteroidal antiinflammatory drugs.
  • Safety Brief: Medication reconciliation white paper available
    ISMP, The Joint Commission, the Institute for Healthcare Improvement, and other healthcare leaders have endorsed a new white paper that gives hospitals recommendations for implementing system-wide medication reconciliation programs. The white paper identifies ten key areas for improvement as well as "first steps" to address each area. For an electronic copy, please visit: http://onlinelibrary.wiley.com/doi/10.1002/jhm.849/full.

Special Announcements

  • ISMP webinars
    • June. On June 29, ISMP will present a webinar on The Pharmacist Perspective: The Expected and Unexpected Results of Computerized Prescriber Order Entry (CPOE) Implementation. Follow the journey of one hospital as it navigates through transformed relationships and altered workflow and efficiency associated with CPOE implementation. Speakers will highlight the challenges to anticipate after the CPOE “go live” date and will share ideas on how to maximize medication safety benefits through the use of CPOE.
    • July. On July 26, ISMP will present a webinar on Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. In traditional patient care units, many organizations have taken steps to improve medication safety. But have improvements been made in areas such as invasive radiology, GI suites, perioperative areas, or ambulatory clinics? Take a tour of these distinct locations with ISMP consulting staff to learn what unique medication safety risks have been uncovered “off the beaten path,” and how to improve safety.

      For details on both webinars, visit: www.ismp.org/educational/webinars.asp.

  • 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.” Sharpen your risk assessment and event investigation skills, and learn more about human errors, Just Culture, Lean Six Sigma, high-leverage error-reduction strategies, and more. The workshop will be held in San Francisco, CA, on September 22-23, 2011. For details, visit: www.ismp.org/educational/MSI.

  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

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