October 6,
2005
- Unfortunately, this time it wasn't the equipment
- Look- and sound-alike names.
Potential confusion may arise between fluoxetine and duloxetine.
- Chemical burns.
Phenol burns a 3-year old child.
- Cafcit label won’t change.
Despite confusion between CAFCIT (caffeine citrate) Oral Solution and Cafcit for injection, the company has informed ISMP that they will not be changing the packaging of these products.
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October 20, 2005
- Preventing magnesium toxicity in obstetrics
- New product labeling.
Novo Nordisk and FDA recently announced package labeling changes to two of their insulin products to help prevent mix-ups.
- Prevent “death by decimal.”
New Duragesic-12 patch may help to prevent medication errors.
- Warning label mix-ups.
A reader suggests separating similar warning labels to avoid mix-ups.
- Quarterly Action Agenda: July – September 2005
ISMP has developed a selection of agenda items and actions to reduce the risk of medication errors at your practice site. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number (in parentheses) to locate additional information as desired. Continuing education credit will be available in the 3 to 4 weeks time for pharmacists and nurses.
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