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The following are excerpts from the newsletter

April 3, 2002

  • Beware of erroneous daily oral methotrexate dosing
  • ISMP Quarterly Action Agenda: January - March 2002
  • Safety Briefs
    • An oncologist prescribed FEMARA (letrozole), one tablet daily by mouth for a postmenopausal woman with recurrent breast cancer. A pharmacist misheard the drug as FEMHRT. The patient picked up the prescription and took the incorrect medicine for approximately two weeks before the error was discovered.
    • Textbook errata: There is an error in the 2002 Mosby's Nursing Drug Reference. On page 1014, in a monograph on insulin aspart (NOVOLOG) and insulin glargine (LANTUS), the "pharmacokinetics" information on the two products was switched inadvertently. .
    • Despite extensive warnings about its teratogenicity, women who are pregnant, or may become pregnant, continue to receive ACCUTANE (isotretinoin), causing severe birth defects in children.
    • The National Quality Forum (NQF) draft consensus report, "Making Healthcare Safer for Patients: Evidence-based Practices," is available on their web site for public comment by April 9 (see www.qualityforum.org ).
    • ISMP will be a cosponsor of the American Medical Informatics Association's (AMIA) 2002 Spring Congress, A Drug By Any Other Name: The Role of Informatics from Drug Development through the Point-of-Care, to be held at the DoubleTree Paradise Valley Resort in Scottsdale, AZ, May 20-22, 2002

April 17, 2002

  • Remote order entry: Innovative practice to reduce distractions and offer 24-hour pharmacy service
  • Complexity of insulin therapy has risen sharply in the past decade - Part I: Data derived from scientific research, voluntary reporting programs, and technology used to automate the medication use process clearly show that insulin errors are frequent and cause significant patient harm.
  • Safety Brief
    • Pharmacists, please complete the ISMP Survey on Pharmacy Interventions. The survey is designed to determine the environment in which pharmacy interventions occur, the most common types of interventions, the processes used to collect and record interventions, and whether the data is used to improve care. Responses are due by May 24, 2002.
    • FDA has approved AVINZA (morphine sulfate extended release) capsules as the first "true once-a-day product" for pain control in patients who require around-the-clock opioid therapy for an extended period of time. Warn patients and staff that Avinza capsules must be swallowed whole and not chewed or crushed due to risk of rapid release and absorption of a potentially fatal dose of morphine. In addition, don't confuse Avinza with INVANZ (ertapenem), a new antibiotic from Merck.
    • Responsibility for error-proofing the system against medication errors extends well beyond clinicians. We recently learned about an information technology (IT) department that sends refurbished computer keyboards to hospital departments to replace malfunctioning keyboards. A used keyboard was replaced at a pharmacy order entry station, only to discover that the "m" key was not functioning. The pharmacy found two order entry errors where "mg" became "g" when printed on medication administration records.
    • Software-related problems also can lead to omitted characters or the display of wrong characters. For example, a Federal Register notice on January 26, 2001, listed the required limits for trace aluminum in small volume parenterals in micrograms, using the Greek character mu for "micro." However, that character does not always translate well or it might not be seen at all in certain word processing programs
    • Ongoing drug shortages continue to cause errors! One hospital ordered heparin 5,000 units Carpuject syringes from Abbott because vials in that concentration were scarce. Unfortunately, a wholesaler sent the 10,000 unit Carpuject syringes, which look identical to the 5,000 unit syringes (both have yellow caps).
    • Looking for expert medication error prevention recommendations to use when performing a root cause analysis or failure mode and effects analysis? A complete set of 150 back issues (January, 1996 to December 2001) of the ISMP Medication Safety Alert!, including photographs, is available on CD-ROM. The material is presented in Adobe PDF format with the Adobe Acrobat Reader included. All articles are searchable using any key word, and they may be copied for your own internal publications and committee work. Visit our web site or call us to place an order.

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