ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook

The full version of the newsletter is available by subscription
Back issues of the newsletter to January 1996 are available on CD-ROM.


November 6, 2008

  • Using external errors to signal a clear and present danger
  • ISMP gains PSO status.

    The Agency for Healthcare Research and Quality (AHRQ) has notified us that our request for certification as a Patient Safety Organization (PSO) has been approved, effective November 5, 2008. ISMP is among the first group of entities granted PSO status. PSOs are organizations in which improvement of patient safety and quality comprise its primary mission and activities. They are being established under the Patient Safety and Quality Improvement Act of 2005. Under our PSO status, practitioners should continue to report medication errors to us as they have in the past and patient safety and quality committees in healthcare organizations can work with ISMP to analyze events and aggregate data to help reduce risks and hazards associated with patient care. ISMP can also work with other PSOs to provide expert analysis on behalf of services offered to their clients. For information, call (215-947-7797) or send us an email (mmandrack@ismp.org).
  • Risk of IV administration of topical thrombin products.

    Topical thrombin should never be injected or otherwise allowed to enter large blood vessels because extensive intravascular clotting and death may result. Surprisingly, in some cases, practitioners were not aware that the product is intended for topical use only. An FDA Patient Safety News video, produced in cooperation with ISMP, details proper use of topical thrombin (www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=78#4). Read more in the newsletter about packaging and labeling risks as well as the ISMP recommendations to reduce the chance of accidental IV administration.

  • Safety Brief: On the “do not use” list.

    An order for DDAVP (desmopressin) was supposed to be given intranasally (IN) but was given intravenously (IV) in error. The order was written below another drug that was ordered IV. The abbreviation “IN” is on our list of abbreviations that should not be used. Learn other options in the newsletter.

  • Safety Brief: New staff intimidation.

    While our 2004 survey on intimidation (www.ismp.org/Newsletters/acutecare/archives/Mar04.asp#mar25) showed that new staff are often shielded from the intimidating behaviors of prescribers, we tend to forget that these staff may be intimidated by the very people who shield them. The code of conduct in an organization should promote an atmosphere where questions are expected and rewarded, regardless of staffs’ rank, experience, or education. Other important steps to help reduce intimidation in the workplace can be found in the newsletter

  • Safety Brief: “Flag” insulin pen labels.

    Once again, we heard about an insulin mix-up that happened when patient-labeled caps on insulin pens were accidentally switched. As a result, one patient received another patient’s insulin before the error was detected. Learn more about the dangers and options for labeling insulin pens to prevent this type of mix-up in your organization.

Special Announcements
  • Celebrate Cheers Stars

    The  Annual Cheers Awards Dinner will be held on December 9, 2008, at Maggiano’s Little Italy restaurant in Orlando, FL. We hope that you will join us in honoring individuals, organizations, and companies that have set a standard of excellence for others to follow in the prevention of medication errors and adverse drug events. If you cannot attend the dinner, please consider making a donation to help support recognition of future advancements in medication error prevention and ISMP’s lifesaving work. To register for the dinner or become a supporter, go to: www.ismp.org/Cheers.

November 20, 2008

  • Actively caring for safety: Overcoming bystander apathy
  • Safety Brief: Antihemophilic factor (recombinant) is factor VIII.

    The carton and vial labeling for KOGENATE FS [antihemophilic factor (recombinant)] does not indicate that the product is factor VIII, which is used to treat patients with hemophilia A. The same problem may exist with other brands of recombinant antihemophilic factor. This product is labeled correctly as antihemophilic factor (recombinant). However, this may be too general, as factor IX is also an antihemophilic factor, which is intended for patients with hemophilia B. Someone with little knowledge of different factor products and types of hemophilia would find it difficult to verify the correct product other than by brand name. Find more information in the newsletter.

  • Safety Brief: Pint-size concentrated acetaminophen.

    We have previously written about a commercially available pintsize container of acetaminophen concentrated drops, PEDIAPHEN (acetaminophen), manufactured by Brookstone Pharmaceuticals where we expressed our concern about the safety of the product labeling. It was hard to recognize as a concentrated product. The labeling has been revised, and
    while we’re happy about the changes, we continue to have concerns about the safety of pint bottles. Read more in the newsletter about our concerns and strategies you can implement to reduce the potential for confusion.
  • Message in our mailbox.

    In our November 6, 2008, newsletter we wrote about an insulin mix-up that happened when patient-labeled caps on insulin pens were accidentally switched.
    We mentioned that a “flag” method might be the best way to label insulin pens to avoid this error. However, a reader had a better idea. Read more in the newsletter.

Special Announcements

  • Celebrate Cheers Stars
    The  Annual Cheers Awards Dinner will be held on December 9, 2008, at Maggiano’s Little Italy restaurant in Orlando, FL. We hope that you will join us in honoring individuals, organizations, and companies that have set a standard of excellence for others to follow in the prevention of medication errors and adverse drug events. If you cannot attend the dinner, please consider making a donation to help support recognition of future advancements in medication error prevention and ISMP’s lifesaving work. To register for the dinner or become a supporter, go to: www.ismp.org/Cheers.
  • Free FDA patient safety videos.

    The latest FDA Patient Safety News videos—including those developed in cooperation with ISMP—are now available free for viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp).

  • ISMP Inaugural Fundraising Campaign

    In 2009, we plan to roll out our inaugural fundraising campaign. We are starting today with the individuals who know us best: our newsletter readers. You are truly the cornerstone of ISMP, serving as the predominant conduit for time-critical medication safety information that now reaches millions of healthcare professionals. As newsletter readers, you have been on an extraordinary journey with us—many since our first publication in 1996—serving witness to needless tragic errors as well as partnering with us to achieve transformational changes to improve medication safety.

    We invite you to make a tax-deductible donation to ISMP to help us achieve our goals in 2009.
    Your gift, small or large, will further our lifesaving work and enhance our capacity to help you protect your patients from medication errors. We thank you for making an investment in our future. Together we are Actively caring for safety:One team, one goal, the power of many.

subscribe now

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
ISMP 17th Annual Cheers Awards
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officer Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP