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The following are excerpts from the newsletter

November 15, 2012

  • Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community

  • Hazard Alert: Potential mix-up between two high-alert drugs could be fatal. A hospital pharmacist found a vial of NovoLOG insulin in the bin where Nimbex (cisatracurium), a neuromuscular blocking agent, is stored. Both are refrigerated high-alert drugs, and both have similar-looking cartons. Two nurses even missed that one of the vials was insulin when shown the bin.

  • Safety Brief: Drug names too close for comfort. Look-alike/sound-alike similarity between clobazam (ONFI) and clonazePAM (KLONOPIN) has led to several reports about the potential for confusion. In one report, a pediatric intensive care unit nurse inadvertently asked for clonazePAM after receiving an order for clobazam.

  • Your Reports at Work. BD will be returning to natural or white syringe tips for both its amber- and clear-barrel oral syringes after reported concerns that amber tips blend into the overall appearance of the amber syringes.

  • New vaccine errors reporting program. ISMP launched its third national patient safety reporting program, the ISMP National Vaccine Errors Reporting Program (ISMP VERP). VERP (http://verp.ismp.org/) captures the unique causes and consequences of vaccine-related errors.

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