The following are excerpts from the newsletter
label confusion, flawed dispensing practice, result in baby's
- JC reaffirms sentinel event policy
- Safety Briefs
- May 98 issue of Nursing 98 includes article
describing root cause analysis of Denver, Colorado medication
- 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
- 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 firstname.lastname@example.org..
- 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
- 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
- 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.