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The following are excerpts from the newsletter

June 28, 2012

  • Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors

  • Safety Brief:  Intralipid 20% or ViperSlide?

    A mix-up is possible between INTRALIPID (intravenous fat emulsion) and a non-drug product called VIPERSLIDE, a lubricant to reduce friction with devices used during atherectomy procedures. While conducting an inspection of an interventional vascular lab, a pharmacist found the ViperSlide product, which has a milky white appearance. It is packaged in a 100 mL bag which looks almost identical to the 100 mL Intralipid 20% bag.

  •  Safety Brief:  Color issue with enoxaparin brand vs. generic.

    The orange color, artwork, and shape used for cartons and overwrap packaging of Sandoz 60 mg/0.6 mL enoxaparin prefilled syringes are similar to that used for sanofi-aventis LOVENOX (enoxaparin) 40 mg/0.4 mL prefilled syringes.

  •  Safety Brief:  Safe injection toolkit available.

    The Centers for Disease Control and Prevention (CDC) has made a toolkit available (www.oneandonlycampaign.org/content/healthcare-provider-toolkit) to help educate healthcare  providers and patients about safe injection practices. Partners of the Safe Injection Practices Coalition (ISMP is a partner) helped create the materials. The toolkit contains posters and print materials that can be downloaded and distributed for in-service education, including videos, PowerPoint slides, and other resources.  The Healthcare Provider Toolkit can be downloaded at the above link or ordered free of charge at: wwwn.cdc.gov/pubs/dhqp.aspx.

  • Safety Brief:  Expiration date unclear.

    The date printed on certain unit dose liquid products manufactured by Pharmaceutical Associates appears to indicate that the item breathed its last breath long ago. One astute nurse complained that the acetaminophen oral solution 650 mg she found in the automated dispensing cabinet seemed to have expired on 4/14/ 2010 (Figure 1). In another hospital, a similar situation was reported with the company’s aluminum and magnesium hydroxides with simethicone, which appeared to expire in 2001! What was thought to be the year was actually a lot number, and “2010” or “2001” was actually “2D10” or “2D01.”

  • 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, please visit: www.ismp.org/educational/webinars.asp.

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