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Back issues of the newsletter to January 1996 are available on CD-ROM.


october 7, 2010

  • Weathering the storm: Managing the drug shortage crisis
  • Safety Brief: Look-alike products
    Be aware of the potential for a dangerous mix-up between two Hospira products. Both boxes and ampuls display a similar yellow and white color pattern. Check out this week’s issue to find out which medications are involved in the potential mix-up.
  • Safety Brief: CQI imperative with smart infusion pumps
    An article about continuous quality improvement (CQI) in con-junction with employment of smart infusion pumps speaks volumes about the value of establishing interdisciplinary teams and devoting financial resources to develop and refine drug libraries. Find out how you can access this article in our current newsletter.
  • Safety Brief: Military versus conventional time
    We have received a couple of questions recently about whether conventional or military time (the 2400 clock) is safer. Sometimes there is confusion as to the meaning of midnight when an order is written or electronically communicated. Learn more about what your organization can do to address this issue.
  • In memoriam 
    ISMP staff were saddened to learn of the recent passing of Dr. Steve Lewis, who served as Chief Medical Officer for CareFusion and was formerly a senior vice president of the Center for Safety and Clinical Excellence. Steve was a graduate of the University of South Florida, College of Medicine, where he also completed an internship in Medicine and residency in Internal Medicine. Dr. Lewis participated in several ISMP safety summits and collaboratives throughout the country and was well respected for his advocacy of medical device safety. His presence will be missed throughout the patient safety community.

Special Announcements

  • Step Up Your Medication Safety Efforts with ISMP. Healthcare practitioners with medication safety oversight responsibilities have an opportunity to join ISMP experts for a 2-day interactive Medication Safety INTENSIVE workshop in Orlando, FL, on November 4-5. Participants will gain cutting-edge knowledge, tools, and strategies to establish a focused medication safety program. For details, visit: www.ismp.org/educational/MSI/.
  • ISMP webinar. Join us on November 17 for HYDROmorphone: Balancing the Benefit and Risk for Patient Care. ISMP invites all safety-minded practitioners to participate! For details, visit: www.ismp.org/educational/webinars.asp.
  • ISMP salutes James P. Bagian, M.D., P.E. Dr. Bagian retired last Friday from the Department of Veterans Affairs (VA) where he served as founding director of the VA National Center for Patient Safety since 1998 and Chief Patient Safety Officer. He is known worldwide for his leadership in patient safety. He has been a steadfast proponent of a systems approach to problem solving, based on prevention, not punishment. He has championed a safety culture beyond medicine’s “name and blame” culture of the past. He currently serves as Chairperson of The Joint Commission Patient Safety Advisory Group, a role in which he will continue. Dr. Bagian has accepted an appointment as a professor in the medical and engineering schools at the University of Michigan and the University of Michigan Health System. We look forward to continued interaction with him.
  • ADC workbook. Facilities that participated in the 2009 ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets (ADC) can now view and print an associated Quality Improvement Workbook. Organizations that have used the self assess-ment are encouraged to utilize the workbook, which contains comparative data collected from responses submitted between June 2009 and February 2010 from 380 hospitals nation-wide. The project is intended to assist organizations in identifying and prioritizing opportunities for improvement related to the safe use of ADCs. To access the workbook, go to: www.ismp.org/selfassessments/ADC/Login.asp. 
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2010 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

october 21, 2010

  • Dakin's solution accidentally given IV
  • Lab change may affect CARBOplatin dosing
    The FDA has alerted the oncology community about a potential dosing problem with CARBOplatin due to changes in the way labs are measuring serum creatinine. Check out this week’s issue to learn more about this potential problem and access FDA’s recommendations.
  • Is ISMP endorsing use of insulin pens in hospitals?
    A back-cover advertisement for the NOVOLOG FLEXPEN (insulin aspart) mentions an ISMP recommendation on the use of prefilled syringes in hospitals, rather than vials. While accurate, this should not be taken as an ISMP endorsement for use of insulin pens in hospitals due to several issues that are discussed in some of our previous newsletters. Find out more in this week’s issue.
  • New TAXOTERE concentration and preparation
    New one-vial Taxotere (docetaxel) in a double concentration is replacing the current two-vial Taxotere packaging which has, over the years, caused reconstitution errors to occur due to confusion regarding overfill in the vials. For additional information, see a letter from sanofi-aventis that can be accessed through our newsletter.
  • Confusing Sandoz packaging
    We’ve asked colleagues at FDA to look into a reported packaging issue with the 100 mg capsules of a generic antifungal. A strip pack labeled 100 mg (see Figure 1 in the PDF version of the newsletter) actually contains two 100 mg capsules. Hopefully, the manufacturer will respond with proper labeling for the product. Until then, if you use this particular generic antifungal brand, relabeling is necessary to assure understanding of the total amount contained in each package. Check out this week’s issue to find out more.

Special Announcements

  • Drug Shortage Summit will take place on November 5, 2010.A coalition composed of the American Society of Health-System Pharmacists (ASHP), the American Society of Anesthesiologists (ASA), the Institute for Safe Medication Practices (ISMP), and the American Society of Clinical Oncology (ASCO) is convening a Drug Shortage Summit on November 5, 2010, in Bethesda, MD. The objectives are to: 1) discuss the scope and causes of drug shortages, 2) shed light on the harm that is occurring to patients due to drug shortages, 3) discuss the potential need for changes in public policy and stakeholder practices to prevent harm from shortages, and 4) develop an action plan that reflects the recommendations and the intent of stakeholders to work together to stop patient harm and disruptions in patient care caused by drug shortages. The meeting will bring together healthcare professionals, organizations, pharmaceutical manufacturers, and supply chain entities. FDA representatives will be in attendance as observers for portions of the meeting.
  • ISMP November webinar. Join us on November 17 (1:30-3 p.m.) for: HYDROmorphone: Balancing the Benefit and Risk for Patient Care. As HYDROmorphone use has become more commonplace, so have reported errors and serious adverse events associated with misunderstandings about equianalgesic dosing, inappropriate patient monitoring, confusion among product concentrations, and mix-ups with morphine. ISMP invites all safety-minded practitioners to participate! For details, visit: www.ismp.org/educational/webinars.asp.  
  • Want to stay informed of ISMP programs and educational activities? Send us your name and email address and we’ll do the rest. There’s a spot for you to “Join our mailing list” by providing this information on our homepage (bottom right) at: www.ismp.org.  
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2010 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

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