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The following are excerpts from the newsletter

July 26, 2012

  • Raising the index of suspicion: Red flags that represent credible threats to patient safety

  • Worth Repeating: Confusion between EpiPen training device and active pen. A report was received about an emergency department automated dispensing cabinet (ADC) being stocked with an EPIPEN (EPINEPHrine injection) training device instead of the active EPINEPHrine 0.3 mg auto-injectors for anaphylaxis.  The manufacturer, Mylan, was again contacted about the packaging of the training device and active pens.

  • Safety Brief: Protocol needed for drug concentration change. A hospital reported that during preparation of a chemotherapeutic agent, a pharmacy technician noticed the concentration of DOCEtaxel in stock had changed.  The computer system did not have the new concentration of DOCEtaxel in its inventory.

  • Safety Brief: How much insulin is in a 3 mL vial? ISMP received a medication error involving Eli Lilly’s insulin 100 units/mL, 3 mL vials.  A nurse preparing an insulin drip read the U-100 (100 units per mL designation) as 100 units per vial.  Communication has been initiated with Lilly and the US Food and Drug Administration (FDA).

  • ISMP webinar. On August 16, ISMP will present Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. For details, please visit: www.ismp.org/educational/webinars.asp.

  • ISMP Cheers Awards. Nominations for this year’s ISMP Cheers Awards are now being accepted through September 14.  For details, please visit: www.ismp.org/Cheers.

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