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1998 medication safety "CHEERS and jeers"


From the Dec. 16, 1998 issue

Our second annual CHEERS and Jeers list acknowledges individuals, organizations and companies that have either set a standard of excellence for medication error prevention, or have frustrated error prevention efforts during 1998.

CHEERS to the Joint Commission on Accreditation of Healthcare Organizations for urging removal of potassium chloride for injection concentrate from patient care areas, and for promoting root cause analysis for sentinel events that focuses on system improvements, not individuals. CHEERS to the Veterans Health Administration for requiring their hospitals to remove potassium chloride for injection concentrate from patient care areas, and for developing a non-punitive error-reporting program for its facilities. CHEERS to the Florida Board of Pharmacy, the first State Board of Pharmacy to promote a non-punitive approach to errors by requiring staff at each pharmacy to examine errors and suggest improvements. CHEERS to organizations that try to provide a non-punitive work environment, and for their willingness to stand firm when faced with a serious or fatal medication error. CHEERS to the Institute for Healthcare Improvement (IHI) for successfully guiding organizations enrolled in their adverse drug event collaborative toward breakthrough improvements in their medication systems.

JEERS to the FDA Center for Devices and Radiological Health for its reluctance to ban infusion pumps without free-flow protection from heath care settings, despite patient deaths and injuries. JEERS also to pump manufacturers who have neglected to recall these hazardous pumps, and continue to sell and support them. JEERS to HCFA for its proposed revisions to the Medicare/Medicaid Conditions of Participation that will likely suppress medication error reporting, and for failing to acknowledge the critical role pharmacists play in error prevention. JEERS to U.S. Rep. Henry Hyde (R-IL) and U.S. Sen. Don Nickels (R-OK) who introduced the "Lethal Drug Abuse Prevention Act of 1998." The defeated legislation would have severely limited aggressive pain management by requiring physicians and pharmacists to prove to the Drug Enforcement Agency that medication was intended for pain relief, not to hasten death.

CHEERS to Stephen Fried, author of Bitter Pills: Inside the Hazardous World of Legal Drugs, which provides an eye-opening look at prescription drug safety and helps to increase consumers' awareness of the important role they play in preventing errors. CHEERS to Thomas Moore for his most recent book, Prescription for Disaster, which sounds an alarm about a nation neglecting the dangers of medications; and for his far-reaching 1998 JAMA editorial on FDA post-marketing surveillance of adverse drug events. CHEERS to Bridge Medical, Inc., for funding and providing U.S. health systems with Beyond Blame, a video that helps organizations create a supportive, non-punitive environment. CHEERS to pharmacist Dennis E. Dunn for participating as a panelist at the 1997 ASHP Midyear Clinical Meeting and for his appearance in Beyond Blame, where he courageously related the emotional turmoil that resulted from his involvement with a serious medication error. CHEERS to nurse practitioner and educator Barbara M. Golz, R.N., M.S., N.N.P., for fearlessly sharing her experiences regarding the profound impact of an infant's death from a medication error in which she was personally involved. Her inspiring presentation at the 1998 ASHP Annual Meeting drew the very unusual tribute of a standing ovation. CHEERS to the jury in Denver that acquitted nurse Kathy King of criminally negligent homicide charges in an infant's medication-error-related death.

JEERS to Ohmeda and Baxter for failing to repackage BREVIBLOC (esmolol) concentrate ampuls to prevent serious mix-ups with the loading dose which is packaged in vials. More than 30 deaths or brain injuries have been attributed to this packaging. JEERS to Parke-Davis, for their failure to re-label CEREBYX despite reports of serious or fatal overdose errors in children and adults. JEERS to Dupont Pharma and McGaw, Inc. These companies have failed to repackage or re-label their IV product, HESPAN (hetastarch), which is frequently mistaken for IV heparin. JEERS to Mead Johnson Pharmaceuticals for reformulating NATALINS RX (60 mg of elemental iron) to ENFAMIL NATALINS RX (27 mg of iron) to circumvent the FDA rule that requires products containing 30 mg or more of iron to be packaged in individual doses to reduce poisoning deaths in children. JEERS to Boehringer Ingelheim, Inc. Neither the ATROVENT Inhalation Aerosol package label, nor the tear-off patient instruction sheet, mentions that the drug is contraindicated in patients with hypersensitivity to soya lecithin or related products, such as peanuts. Thus, peanut-allergic asthma patients and their health professionals may be unaware of this critical information. JEERS to the FDA Division of Drug Marketing, Advertising, and Communications (DDMAC) for permitting ongoing pharmaceutical advertisements that incorporate medical abbreviations deemed dangerous by the National Coordinating Council for Medication Error Reporting and Prevention, of which FDA is a founding member.

CHEERS to the American Society of Health-System Pharmacists (ASHP) for strongly encouraging FDA action to improve label readability, drug naming, bar-coding on drug packaging, and pre-market evaluation of new products. CHEERS to The Liposome Company, Inc., for sponsoring a national alert about serious and fatal errors that occur when lipid-based products are confused with their conventional counterparts. CHEERS to Bristol-Myers Squibb Oncology/Immunology for safety-conscious label redesign, funding an advisory panel to recommend chemotherapy error prevention strategies and educational events on chemotherapy error prevention. CHEERS to pharmacy educator Bruce Lambert, Ph.D., of the University of Illinois at Chicago, for developing a highly sensitive computer screening method to make predictions about error potential for look-alike and sound-alike drug names. Our LOUDEST CHEERS to all those practitioners who, in 1998, reported adverse drug events. Without those reports, ISMP and others in the field of medication error prevention could not review them, learn from them, and spread the word effectively so that we can prevent the same errors from happening again.

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