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The following are excerpts from the newsletter


November 3, 1999

  • Safe practice recommendations for using vitamin K1 to reverse excessive warfarin anticoagulation
  • Increased potential exists for misprogramming devices that automatically calculate infusion rates
  • Safety Briefs:
    • With a severe shortage of penicillin G potassium or sodium CDC has issued suggestions for alternatives. Use caution with the administration of these alternatives.
    • Glaxo Wellcome has voluntarily withdrawn RAXAR (grepafloxacin) due to a small number of patients who experienced severe cardiovascular events (torsade de pointes).
    • Nitroglycerin transdermal patches, distributed by Mylan Pharmaceuticals, are clear and blend in with skin color so well that they are nearly invisible. As a result, patch removal may be missed or forgotten.
    • In our last issue we mentioned that a table in the current (6th) edition of Lexi-Comp's The Pediatric Dosage Handbook incorrectly lists doses of midazolam (VERSED) in mg rather than mg/kg. However, we cited the page number for the 5th edition (page 1284), which also has the dose expressed erroneously. The table in the 6th edition is on page 1070.
    • NATRU-VENT, an OTC saline nasal spray manufactured by Boehringer Ingelheim Consumer Healthcare Products, has a name that looks and sounds like their prescription inhaler, ATROVENT (ipratropium).
    • Last week, mass media attention was focused on a case in Odessa, TX, where a cardiologist was held liable for a fatal medication error caused by poor handwriting.
    • ISMP's Board of Trustees is delighted to be hosting its second annual Cheers Awards Dinner, at the ASHP meeting on Tuesday evening, December 7, 1999. Call for more information.

November 17, 1999

  • Extraordinary similarities exist between infection control and medication error prevention
  • Dosing cards for Aggrastat may lead to error
  • Safety Briefs:
    • Influenza Virus Vaccine labeling may cause confusion.

      Top: Picture of Vaccine for patients 13 years and older
      Bottom: Vaccine for patients 6 months and older
    • FDA provides Y2K information regarding drug shortages at
    • Correction! Due to a misprint, the ISMP Quarterly Action Agenda for July - September 1999 (published in our October 6th issue) indicated that ferrous sulfate drops contain "75 mg of elemental iron per 0.6 mL." Ferrous sulfate drops contain 75 mg of ferrous sulfate, or 15 mg of elemental iron, per 0.6 mL. Please note the correction on your Action Agenda.
    • Bayer Corporation is relabeling the diluent for CIPRO Oral Suspension to help prevent mistakes.

      Picture of new Diluent label
    • Last week, another error with Cipro was reported where the nurse administered the entire 100 mL container of Cipro (10 g/100 mL) instead of 5 mL (500 mg) as ordered, despite pharmacy labeling of the dosage and volume to be administered.
    • The Institute of Medicine is about to publish report on error in medicine and what needs to happen within health care organizations. Linda Kahn, Ph.D., co-director of the project will be keynote speaker at ISMP's Cheers Awards Dinner.
    • ISMP Exhibitors' Theaters at the ASHP Midyear Clinical Meeting
      Mon. December 6, 1999.......Chemotherapy To Do List: Expert Advice
      Tues. December 7, 1999......Closing the Patient Safety Loop: Applying Today's Technology Throughout the Drug Use Process

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