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The following are excerpts from the newsletter

May 16, 2013

  • Administering a saline flush "site unseen" can lead to a wrong route error
  • Null sign easily misread
    A zero written with a slash through it (Ø) to differentiate it from the letter O can lead to medication errors due to misinterpretation as the number 4, 6, 8, or 9.
  • HYDROmorphone available in 0.5 mg prefilled syringe
    As a result of serious adverse drug events, FDA reduced the recommended starting dose of HYDROmorphone to 0.2-1 mg in June 2011. To address these lower doses, Hospira recently released HYDROmorphone 0.5 mg/0.5 mL injection in its proprietary iSecure prefilled unit-dose syringe.
  • New ideas to address drug shortages
    On April 18, 2013, ISMP joined the American Society of Health-System Pharmacists (ASHP), the American Hospital Association (AHA), the American Society of Anesthesiologists (ASA), and the American Society of Clinical Oncology (ASCO) in co-convening a follow-up meeting to address the current drug shortage situation.
  • Name confusion with new cancer drugs
    Two new oral chemotherapy agents have names that may cause confusion. Pazopanib (VOTRIENT) is used to treat renal cell cancer, thyroid cancer, and soft tissue sarcoma, while ponatinib (ICLUSIG) is used to treat chronic myelogenous leukemia and Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia.

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