january 28, 2010

• Baclofen programming error with SynchroMed II pump
  Facility not made aware of company’s software updates
• Safety Brief: Problematic bar code.

  The Veterans Health Administration Bar Code Resource Office has alerted us to an issue regarding scannability of a topical fluorouracil product.  Check out the newsletter to find out if this is a product you utilize at your facility and how this scanning issue may affect your organization.

• Safety Brief: “Catching deadly drug mistakes.”
  
  On January 18, 2010, the Wall Street Journal published an article entitled, “Catching deadly drug mistakes” (http://online.wsj.com/article/SB10001424052748703626604575010932945077528.html), which touched on the National Alert Network for Serious Medication Errors (NAN) that ASHP is coordinating with ISMP, ISMP’s efforts to address medication errors, and a new effort by The American Association of Eye and Ear Centers of Excellence to improve labeling of ophthalmic and otic solutions. 
• Safety Brief: A different type of allergy problem.
  
  During a hospitalization, “vitamin D” was entered into the allergy field of a patient’s medical record, although the patient had never reported any adverse effects from the vitamin.  On subsequent medical visits, the erroneous information remained in the patient’s medical record even after repeated requests for its removal.  Learn why this information was not corrected and if this may be an issue within your healthcare organization.

• March 7-13: Patient Safety Awareness Week.
  
  If you are planning events for patients, community groups, or area businesses, consider showing Patients Play a Vital Role in Patient Safety, a video distributed by ISMP. The program is just 20 minutes long, but it covers realistic scenarios of risks, and practical, expert advice to help patients become active participants in their own care and safety. Hospitals are also encouraged to show this video on their patient education channel; suggested viewing locations include preadmission testing and outpatient waiting areas. To order a copy, visit: http://onlinestore.ismp.org/shop/item.aspx?itemid=146.
• ISMP webinar. 
  
  Please join us on February 18, 2010, for Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets (ADCs). Preliminary data since the launch of the self assessment will be presented along with recommendations to further improve the safe use of ADCs. For details and to register, please visit: http://www.ismp.org/educational/webinars.asp.