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The following are excerpts from the newsletter

June 14, 2012

  • Dr. Leape and colleagues present a compelling call to action to establish a culture of respect

  • Safety Brief:  Caution!  ChemoPlus gown may not afford worker protection.

    Looking at the product name—ChemoPlus—health professionals may believe that Covidien ChemoPlus Protective Gowns offer all the protectionthat pharmacists or nurses need against personal exposure to chemotherapy drugs during preparation or administration. But a pharmacist recently reported that a technician he works with experienced an exposure to a non-chemotherapy drug despite wearing this gown.  While preparing a dose of iron dextran injection, the technician accidentally sprayed the drug onto her ChemoPlus gown sleeve and found that the solution had seeped through the gown and onto her clothes.

  •  Safety Brief:  Archaic liquid measure a factor in medication errors.

    Last year the ISMP Board of Trustees and staff documented their support for the complete adoption of the metric system for prescribing and measuring liquid doses (www.ismp.org/pressroom/PR20110808.pdf). All too often, mix-ups between drops and mL, teaspoons and mL, and minims and mL have caused serious medication errors. So have abbreviations such as TSP and TBSP, which sometimes appear on dosage cups. Now we can also add confusion between “drams” and mL. A nurse recently gave a patient 5 drams of acetaminophen concentrate liquid (100 mg/mL) instead of 5 mL. That’s 18.45 mL, or 1.845 g of cetaminophen!

  • ISMP consumer website updated

    ISMP has redesigned our medication safety website for consumers, ConsumerMedSafety.org www.consumermedsafety.org ). The website has a wide array of consumer-oriented safety alerts, medication error reports, articles, drug information, and medication identification resources. There are also a number of useful medication safety tools, an insulin safety center, patient information sheets on high-alert drugs, videos on safety topics, and a system for consumers to report medication errors to ISMP and the US Food and Drug Administration (FDA). As a result of the recent announcement about the FDA and ISMP partnership ( www.fda.gov/ForConsumers/ConsumerUpdates/ucm297644.htm ), a special section of the website highlights consumer information from FDA. Hospitals should consider how the website might benefit their patients. For example, you may want to promote use of the website to your patients by including a link to the website in any consumer information you publish, including drug information sheets, and on your hospital’s website. Visit our updated website soon!

Special Announcements:

  •  ISMP Cheers Awards

    Nominations for this year’s ISMP Cheers Awards are now being accepted through September 14. The Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors during the previous year. For details, please visit: www.ismp.org/Cheers/ .

  •   ISMP webinars. 

    On July 12, we will be presenting Patient Information Matters: Reducing Harmful Errors Associated with Weights and Allergies. Please join ISMP as we describe the unique challenges associated with obtaining and using this valuable information by discussing the analysis of actual medication errors and strategies for error prevention.

    On August 16, ISMP will present Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. Take a tour of diagnostic and procedural areas with ISMP consulting staff to learn what unique medication safety risks have been uncovered “off the beaten path.” For details on both webinars, visit: www.ismp.org/educational/webinars.asp.

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