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The following are excerpts from the newsletter

August 9, 2012

  • ISMP survey reveals user issues with Carpuject prefilled syringes

  • Safety Brief:  Medication within IV tubing may be overlooked.
    After surgery, a patient’s IV line was flushed by a nurse in the post-op recovery area. About 2 minutes later, the patient stopped moving or breathing, and his oxygen saturation fell to 40%. It is likely that several mg of rocuronium were present in the IV tubing used by anesthesia and inadvertently flushed into the patient.

  •  Safety Brief: Searching by drug name gives information on wrong drug.
    A nurse who was discharging a patient from the hospital was reviewing the patient’s medications, which included tranexamic acid (CYKLOKAPRON) 500 mg, a drug for certain bleeding disorders that the patient did not have. The patient said he was taking RANEXA (ranolazine) 500 mg for angina. The hospital’s computer system listed tranexamic acid when searching for Ranexa as the name Ranexa is completely and correctly spelled within the word tranexamic acid.

  • Worth Repeating: Phosphate enemas may pose problems for renal patients.
    An elderly woman, who had been admitted with acute renal failure, also had constipation and received two Fleet enemas, each containing 7 g of dibasic sodium phosphate and 19 g of monobasic sodium phosphate or more than 160 mmol of phosphate. The patient subsequently developed secondary hypocalcemia due to diminished phosphate clearance from her renal failure.

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