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The following are excerpts from the newsletter

May 6, 1998

  • Cerebyx® label confusion, flawed dispensing practice, result in baby's death
  • JC reaffirms sentinel event policy
  • Safety Briefs
    • May 98 issue of Nursing 98 includes article describing root cause analysis of Denver, Colorado medication error.
    • Hospital risk managers and pharmacy directors should give high priority to reviewing procedures and practices related to handling potentially toxic topical and chemical substances throughout the institution. Then, ongoing monitoring should occur during regular visits to patient care areas, including surgical areas and on-site group practice facilities.
    • ISMP provides the ISMP Medication Safety Alert! at no charge to full-time faculty at schools of pharmacy, nursing and medicine so that the experiences reported through the USP Medication Errors Reporting Program can be transformed into important lessons for students. Faculty may arrange to receive complimentary e-mail subscriptions by contacting us at
    • Bar code technology is now being used in an Eckerd Pharmacy in Atlanta, GA to help ensure that the correct drug and strength are dispensed to the patient.
    • Two new methods for "detextualizing" may help in reducing medications errors.
    • O.R. mishaps: How much does "Lasix 10 mg IV" sound like "Lasix 100 mg IV"? Not much ordinarily, but when the prescriber is wearing a mask in the middle of surgery, verbal orders may all too easily be misunderstood.
    • Prepare to program your computer with these latest name mix-ups: If written poorly, orders for the new product Regranex® (becaplemin), a topical gel for lower extremity diabetic ulcers, could easily be confused with Granulex® (trypsin, balsam Peru, castor oil), a topical aerosol also used on ulcers.

May 20, 1998

  • Willingness of staff to give oral meds IV is disconcerting
  • Suggestions for resolving conflicts in drug Therapy
  • Safety Briefs
    • Nurse uses amrinone from automated dispensing cabinet when amiodarone was ordered leading to a patient's death.
    • Confusion may occur when dosing patients with the new formulations of Enfamil Natalins Rx® from Mead Johnson. Each tablet now contains only 27 mg of Iron and the labeled dose is two tablets daily.
    • The most frequently cited medication mix-ups reported to the USP Medication Errors Reporting Program or FDA's MedWatch Program are Proscar® and Posicor, Norvasc® and Navane™, Prilosec® and Prozac®. These medications need special handling by pharmacists because the names look so similar, especially when handwriting isn't clear.
    • European Medicines Evaluation Agency (EMEA) the European equivalent to the US's FDA has published a guidance statement to help companies when they submit names for new drug products. FDA is currently considering various new initiatives to prevent medication errors with pre-approval testing of labeling, packaging and proprietary names.
    • To prevent errors with neuromuscular blocking agents, we've often suggested having pharmacy dispense the drugs as needed, instead of stocking them in patient care areas. However, even with pharmacy dispensing these drugs, safeguards are needed to prevent their inadvertent use in patients who are not mechanically ventilated.
    • Over the past few years health care has undergone rapid change, and in an effort to stay above water, many organizations have been resorting to downsizing. Prior to any staff reductions, please give very careful consideration to safe medication practices.

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