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Messages in our mailbox

From the January 9, 2002 issue

In addition to the wonderful feedback we receive from our regular surveys, many readers send us comments about various features in the newsletter. Often they provide great examples of how the information was put to use, how it averted an error, or additional error prevention strategies that have proven successful in their organization. For example, in response to our October 17, 2001, article on the danger of concomitant use of unfractionated heparin and low molecular weight (LMW) heparin, one reader told us how he successfully screens for interactions with one-time heparin doses given in the emergency department (ED). With many pharmacy computer systems, a one-time drug order becomes inactive as soon as it's dispensed, but the interaction check system occurs only with active orders. To solve this problem, the pharmacist now enters one-time doses of LMW heparin as a set of two orders. The first order is for the LMW heparin as prescribed and administered in the ED. The second order is actually a note that the patient has received the LMW heparin and includes the drug's interactive NDC number and a suggested frequency that would keep the order active for about 12 hours. Thus, an interaction message would occur if another heparin product were prescribed within that time frame. While modifications for different computer systems may be necessary, many would allow such a safety net to be built.

In response to our September 19, 2001, article on problems associated with confusion between concentrated and conventional forms of oral liquid morphine, another reader told us that she was able to eliminate all stock of liquid concentrated morphine by replacing it with various strengths of soluble morphine tablets. Incremental dosing is easy because the soluble tablets are available in 10 mg, 15 mg, and 30 mg strengths. Nurses select the appropriate dose in tablets and dissolve them in a small amount of water immediately before oral administration. Eli Lilly, the company that manufacturers the product for Ranbaxy Pharmaceuticals, has confirmed that there are no problems with stability, contamination, bioavailability, or absorption when the tablets are used in this manner. Using soluble tablets when higher doses of oral morphine are needed helps avoid the risk of confusion with the morphine liquid (10 mg/5 mL) currently available in unit dose cups.

It's also worth mentioning an additional caution from one of our subscribers about an article in our December 12, 2001, newsletter on mix-ups between pediatric/adolescent and adult formulations of ENGERIX-B (hepatitis B vaccine). In the newsletter, we noted that the absence of a specific prominent "pediatric/adolescent" notation on cartons of the 10 mcg/0.5 mL pediatric Engerix-B dose has led to accidental administration of this lower dose to adults (who should've received a 20 mcg dose). Our reader let us know that, because of more favorable pricing on syringes containing the pediatric/adolescent dose, healthcare providers may be tempted, or even encouraged, to use two pediatric doses to equal one adult dose. Such a practice, combined with ambiguous labeling on the pediatric/adolescent formulation, may further increase the risk of mistakenly giving a pediatric/adolescent dose to an adult, which would not provide the desired immunologic enhancement. If you stock the pediatric formulation, take time now to add an auxiliary label or mark it with a pen.

We would love to hear if you have additional suggestions on how to avoid errors that have been reported in our newsletter, or other related warnings. Send your comments to us. We hope to make your "messages in our mailbox" an ongoing feature in the 2002 ISMP Medication Safety Alert!

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