The following are excerpts from the newsletter
- Systems thinking:
Tap into staff creativity to unleash innovation
- ISMP Quarterly
Action Agenda: July - September 2001
- Safety Briefs:
- Naloxone 0.4 mg/mL and heparin 5,000 units/mL packaged
in Abbott's prefilled Carpuject syringes are very similar
in appearance to boxes of phenytoin 100 mg/2 mL Carpujects.
- An elderly woman was prescribed amitriptyline to treat
a neurogenic pain syndrome, but her physician didn't
tell her why it was being prescribed or write the reason
for the medication on the prescription.. While counseling
the patient, a pharmacist described the medication as
an antidepressant. The patient became angry, refused
the medication, and accused her physician of believing
her pain was all in her head.
- Guidance regarding bioterrorism preparedness and response
can be found at the Johns Hopkins Center for Civilian
Biodefense Studies web site (http://www.jhsph.edu/preparedness/tips/topics/index.html)
and the Centers for Disease Control and Prevention emergency
preparedness web site (www.bt.cdc.gov).
- We are now accepting nominations
for the 2001 ISMP Medication Safety Alert! Subscriber
Award to honor an organization that has proactively
used this publication to improve medication safety.
- ISMP hosts the 4th Annual Cheers and Lifetime Achievement
Awards Dinner and Reception at 6 p.m., December 4, 2001,
during the ASHP Midyear Clinical Meeting at the Hilton
New Orleans Riverside. James P. Bagian, MD, PE,
Director of the Department of Veterans Affairs National
Center for Patient Safety, will be the keynote speaker.
Lucian L. Leape, MD, internationally renowned
expert on medical errors and prevention efforts, will
receive the first annual ISMP Lifetime Achievement Award.
- Failure Mode and
Effects Analysis can help guide error prevention efforts
- Insulin syringe is not meant for U-500 insulin
- Safety Briefs:
- Congratulations to those who report medication safety
issues to USP, ISMP and FDA. As a result, several longstanding
medical product safety issues have been resolved. Eisai
and Janssen have changed the package label appearance
for ACIPHEX (rabeprazole sodium) to help differentiate
it from ARICEPT (donepezil), one of their other products.
Also, Merck has addressed problems you've been reporting
about look-alike unit dose packaging. They've reduced
the risk of product misidentification by using distinct
color schemes for products within the same classification
with alternating geometric shapes and reversed backgrounds
to highlight product strengths. PRINIVIL (lisinopril),
PROSCAR (finasteride) and ZOCOR (simvastatin) label
changes have been introduced already, as these products
have been associated with dispensing errors most frequently.
Also, you may have seen recent journal advertisements
announcing that GlaxoSmithKline has substantially changed
the container labeling to reduce the potential for dispensing
errors due to confusion between its antiepileptic drug,
LAMICTAL (lamotrigine) and LAMISIL (terbinafine), a
Novartis product. The new label highlights the ".ICTAL"
part of the name by italicizing it and placing it in
a yellow background with red characters (LAMICTAL).
In addition, a message has been placed on the front
label panel stating: "CAUTION: Verify Product Dispensed."
Finally, Andrx Laboratories has discontinued use of
the proprietary name PROCET for its hydrocodone bitartrate
and acetaminophen tablets. Instead, the trademark ANEXSIA
will be used with this product. In our September 5,
2001 issue, we mentioned Procet as an example of a loophole
in federal regulations that allows generic firms to
avoid trademark review by FDA if they distribute a drug
but do not hold the abbreviated new drug application
(ANDA) which, in this case, is held by Mallinckrodt.
FDA now intends to close that loophole through issuance
of a guidance statement. We thank the companies and
FDA for taking action on the concerns expressed by our
reporters. But most of all, we thank you for reporting
- Another tragic death caused by concomitant use of
low molecular weight heparin (LMWH) and unfractionated
heparin another tragic death caused by concomitant use
of low molecular weight heparin (LMWH) and unfractionated
heparin reported to ISMP.
- Education provided to patients while in the physician's
office can arm them with the information needed to prevent
- ABC News recently reported that four people were arrested
after breaking into a veterinarian's office to search
for OXYCONTIN (oxycodone, controlled release).
Instead, they oxydentally took oxytocin).
- Based on a single letter sent to the managing editor
of American Diabetes Association professional journals,
a new policy to prohibit the use of the abbreviation
"U" for units has been instituted. Packaging changes
for ACIPHEX (rabeprazole sodium), and ARICEPT (donepezil
HCl), lead to near miss.
on practice site distribution of the ISMP Medication Safety Alert!
- To promote understanding,
assume every patient has a health literacy problem
- Action needed to prevent dangerous
- Safety Briefs:
- An Ohio pharmacist has been indicted by a local grand
jury for dispensing a fatal overdose of chemotherapy
to a patient with multiple myeloma.
- A neonatal intensive care unit nurse called the pharmacy
she stated that she needed "A PRISCOLINE
(tolazoline) drip," but the pharmacist misunderstood
her to say "APRESOLINE drip" (hydralazine).
- A patient was ordered REMICADE (infliximab)
via IV pump. Unfortunately, the tubing from a bag of
saline that also was hanging on the IV pole was accidentally
threaded through the pump instead of the intended solution.
As a result, the Remicade solution infused at an uncontrolled
- A hospital reported mix-ups between two different
"rubicin" products (anthracyclines).