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The following are excerpts from the newsletter

July 17, 2014

In this week's issue:

  • With oral chemotherapy, we simply must do better!
  • B. Braun 1,000 mL potassium chloride premix.
    • Mislabeled cartons of 1,000 mL bags were distributed to hospitals by B. Braun. The boxes were labeled 5% dextrose and 0.45% sodium chloride on one side and 0.15% potassium chloride (20mEq) in 5% dextrose and 0.45% sodium chloride on the opposite side. A single lot number of the product is affected and the company is working to resolve the issue.
  • Duplicate the drug name on commercial labels.
    • A technician accidentally mixed a vial of trastuzumab (HERCEPTIN) with a vial of riTUXimab (RITUXAN) instead of 2 vials of riTUXimab. Additional details from the report and recommendations are discussed in this safety brief. 
  • GLUCAGON label contributes to confusion.
    • We recently received a report where a nurse gave an incorrect dose of glucagon because of the way the dose is expressed on the label of Lilly’s Glucagon Emergency Kit. Instructions for properly administering doses of glucagon are provided. 
  • Quarterly Action Agenda (April - June 2014)

Special announcements...

  • ISMP's Annual Fund
    • The healthcare community would be very different without ISMP's existence over the last 20 years(For a list of ISMP's many important contributions to safety, please visit: www.ismp.org/about/timeline.asp.) We depend on the caring individuals and organizations that passionately support our work. Your charitable donation to the Annual Fund will help keep ISMP an important part of the fight against preventable medication errors.
    • To make a donation, go to: www.ismp.org/support.
  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Nashville, TN on October 2-3. This workshop provides hands-on experiences with event investigation, risk analysis, error-reduction strategies, action planning, Just Culture, and more!
    • For details, visit: www.ismp.org/sc?id=351.

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