ISMP Medication Safety Alert! Acute Care Edition

Patient's watchful eye and Internet lead to pump tampering
Unsafe TYLENOL (acetaminophen) packaging could lead to double dosing in children.
Physician-coined abbreviations (DCN, PROXL, and DPH) cause confusion and errors.
ISMP Quarterly Action Agenda

April 21, 2005

Building a case for medication reconciliation
Non-standard abbreviations, such as "PT", can have multiple meanings and lead to misinterpretations.
ANUSOL topical starch products are now labeled as TUCKS, the trademark associated with topical witch hazel products.
REMINYL (galantamine) trademark changed to RAZADYNE to prevent mix-ups with AMARYL (glimepiride).
New USP resolution to encourage use of generic names only in practice settings may not lead to fewer errors.

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