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The following are excerpts from the newsletter

April 4, 2001

  • Part II of Our National Survey on Drug Shortages: Proactive Guidelines to Safely Manage Scarce Supplies
  • ISMP Quarterly Action Agenda: January - March 2001
  • Safety Briefs
    • Caution: Packaging of the new IV bag of BREVIBLOC (esmolol) Premixed Injection could lead to errors. A foil outer-wrap lists the drug's identity on one side only. When the bag is turned over, its appearance is identical to the Baxter dopamine premixed bag.
    • We were delighted to learn this week that FDA's Division of Generic Drugs has acted on a suggestion of ours to decrease errors with look-alike drug names. For years we have urged generic manufacturers to use a combination of large and small letters (e.g., chlorproMAZINE and chlorproPAMIDE) to help distinguish drugs with look-alike names, especially when they share similar strengths. Although we've only met with marginal success, the method has successfully eliminated problems with other products such as diphenhydrAMINE and dimenHYDRINATE. Recently, FDA asked certain manufacturers of generic drugs to differentiate similar name pairs in the manner noted above. Letters were sent to firms that manufacture the following: Acetohexamide, acetazolamide, chlorpropamide, clomipramine, daunorubicin, doxorubicin, dopamine, and dobutamine. To date, 33 letters have gone out for 44 generic drug applications and more are planned. Hospitals should follow suit by making similar changes in their own labels, preprinted order forms, computer screens and printouts, and drug storage location labels.
    • In our March 11 issue, we mentioned that differentiation of the 20 mg/mL and 100 mg/mL concentrations of QUELICIN (succinylcholine) injection may be difficult due to similar appearance of the package label. Abbott Laboratories has informed us that changes are underway to improve labeling. Right now, there is a significant nationwide shortage of the product, which may contribute to confusion between the two concentrations.
    • In our March 11 issue, we mentioned that differentiation of the 20 mg/mL and 100 mg/mL concentrations of QUELICIN (succinylcholine) injection may be difficult due to similar appearance of the package label. Abbott Laboratories has informed us that changes are underway to improve labeling. Right now, there is a significant nationwide shortage of the product, which may contribute to confusion between the two concentrations
    • Aventis Pharmaceuticals initiated a voluntary recall of TAXOTERE (docetaxel) for Injection Concentrate, 20 mg active ingredient and diluent vials. Certain lot numbers containing the active drug may have inadvertently been labeled as a "diluent" vial. In our June 2, 1999 issue, we reported a mix-up between the diluent and active product, both of which have nearly identical labels (a photograph is on our web site).

April 18, 2001

  • Lessons lost by the global pharmaceutical industry
  • Fentanyl transdermal system: unsafe in inexperienced hands
  • Safety Briefs
    • Packaging of CAFCIT ORAL SOLUTION (caffeine citrate) is similar to CAFCIT IV injection. Both are clear, colorless liquids packaged in single dose vials sealed with Teflon-faced gray rubber stoppers and aluminum ferrules. We already have several reports where the oral solution vial was dispensed instead of the IV vial.
    • A recent "near miss" with oral amphotericin B should give you cause for concern. A solution was made from the parenteral product (FUNGIZONE INTRAVENOUS) which provides just 5 mg/mL after reconstitution instead of using commercially available FUNGIZONE (amphotericin B desoxycholate) oral suspension (100 mg/mL). A nurse called to inform pharmacy that the patient had a GI bleed and needed IV medications. She asked if she could draw the amphotericin B into a syringe to administer the dose IV.
    • Two letters recently suggested a need for increased monitoring of ZYVOX (linezolid). The first encouraged pretreatment susceptibility testing while the second emphasized the need to monitor the patient's CBC.
    • ISMP currently has positions open for a medical writer as well as nurses and pharmacists with clinical experience and strong management skills. Excellent writing ability is required for all positions. Relocation to the Philadelphia area is also required.
    • ISMP Canada has been awarded a grant by the Ontario Ministry of Health to study the impact of ISMP Canada's interventions for improvement of medication use in some Ontario hospitals

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