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The following are excerpts from the newsletter

October 18, 2012

  • Sterile compounding tragedy is a symptom of a broken system on many levels

  • SafetyBriefs: Arixtra is not a hemostat. Twice within the past 3 months, at the same hospital, ARIXTRA (fondaparinux sodium) was dispensed instead of “Aristra”. The product he was actually looking for was ARISTA AH, a synthetic, absorbable hemostatic agent.

  • WorthRepeating... Preventing mix-ups between various formulations of amphotericin B. Given current recommendations from the Centers for Disease Control and Prevention (CDC) for treatment of fungal meningitis in patients infected by contaminated injections dispensed from a New England compounding pharmacy, we want to remind healthcare providers of the risk of confusion between confusion between liposomal and conventional formulations of IV amphotericin B.

  • SafetyBriefs: USP Prescription Container Labeling standard. Pharmacopeia (USP) has created a prepublication webpage on outpatient prescription container labeling (General Chapter <17>).

  • SafetyBriefs: AHRQ and consumer error reporting. The Agency for Healthcare Research and Quality (AHRQ) has issued a Federal Register Notice regarding its intent to test a consumer reporting program for medical errors in 2013.

  • ISMP Symposium. ISMP invites you to join us for Midday Symposia #5: Reducing IV Admixture-Related Safety Risks: A Review of the ISMP Sterile Preparation Compounding Guidelines, on December 3 during the ASHP Midyear Clinical Meeting in Las Vegas, NV. For more information, please visit: www.ismp.org/pressroom/Symposium2012.asp.

  • ISMP webinar. Please join us on October 24 for Challenges in Neonatal Intensive Care Medication Safety: Identifying Risk and Opportunity. For details, please visit: www.ismp.org/educational/webinars.asp.

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