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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

April 5, 2007

  • Failure to clearly link TYLENOL products to acetaminophen poses serious threat to safety
  • “20/20” captures community pharmacy errors, but vision seems to be shortsighted
  • Many television viewers tuned in to 20/20 (ABC) to watch the exposé on prescription errors, “A prescription for disaster”. The segment was intended to provide answers to two very important questions: 1) Who is the person behind the counterfilling your prescription?2) Are you getting the medication yourphysician prescribed? The program seemed to miss its mark on both accounts. Click here to read more.

  • Don’t reapply barcode labels
  • Ripping off and reapplying pharmacy generated barcode medication labels may lead to incorrect scans at the bedside.

  • HUMIRA Pen and HumaPen
  • HUMAPEN MEMOIR is a pen device that was recently launched for use with HUMALOG (insulin lispro injection [rDNA origin]). Don’t confuse this new product with HUMIRA PEN (adalimumab).  Both brand names look and sound nearly identical.

  • Replacing outdated drugs
  • A pharmacist reported concern with the process used by Genentech, the manufacturer of ACTIVASE (alteplase) and TNKASE (tenecte-plase), to replace these products upon expiration. If the drug has reached the expiration date listed on the carton, the company asks a hospital representative to open the package to determine if it is the diluent or actual drug that is outdated. If it is the diluent, a new vial of diluent is sent for replacement in the original package and the outer carton’s expiration date must be changed.

  • Unsafe abbreviation
  • A pregnant woman was prescribed “PNV” tablets (“prenatal vitamins”). The pharmacist assumed that PNV stood for “penicillin VK” and dispensed penicillin tablets in error.

Special Announcements…

  • High-alert medication survey
  • We need your help! Please help determine the ISMP high alert drug list for 2007: Visit www.ismp.org/survey/survey200702.asp to complete our survey on high-alert medications.

  • ISMP Safe Medication Management Fellowship
  • Jump start your career in patient safety:---ISMP Fellowship now accepting applications. For an application and more information, please visit: www.ismp.org/profdevelopment/managementfellowship.asp.

  • ISMP teleconference
  • Barcoding at the Point-of-Care to Enhance Medication Safety, Part II: Lessons From the Bedside, April 4, 2007.  Janice Dunsavage, RPh, MS, from PinnacleHealth in Harrisburg, PA, provides a first-hand look at the challenges faced by an organization that has successfully implemented a barcoded drug administration system. For more information please visit:  http://www.ismp.org/educational/teleconferences.asp.

  • Educational Programs
  • Join ISMP at the unSUMMIT! Bedside Barcode Technology in Practice, May 9-11.  Basic and advanced tracks and post-conference workshop by ISMP on using bar-code point-of-care data to drive quality improvement, monitor implementation progress, and enhance medication safety. For more information or to register, visit www.unsummit.com or call 412-287-5108.

    Just Culture training. Outcome Engineering, LLC, curators of the Just Culture Community (www.justculture.org), will offer its next public course on JustCulture Training on April 17-18 in Dallas,TX. This course is the entry point for those seriously desiring to change their organizational culture through use of the Just Culture Community tools. For more information, visit: www.justculture.org/pge_publiccourse.asp.


    NPSF Congress.
    The National Patient Safety Foundation (NPSF) will be holding its 9th annual patient safety congress on May 3-4 in Washington, DC. For details and to register, visit: www.npsf.org/congress/index.html.


April 19, 2007

FDA has failed to issue official guidance to pharmaceutical industry that would facilitate consistency in the way drug concentrations are expressed on package labels

  • Mcg vs. mcg/kg

Errors result when the dose of a medication is displayed on a MAR differently than the way the information is needed to be programmed into an infusion pump

The January – March 2007 ISMP Quarterly Action Agenda appears in the PDF version of the newsletter. Subscribers can also download a Word version of the Action Agenda (www.ismp.org/Newsletters/acutecare/articles/actionagenda0702.doc), which allows expansion of the boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Special Announcements…
  • Educational Programs
  • NPSF Congress. The National Patient Safety Foundation (NPSF) will be its 9th annual patient safety congress on May 3-4 in Washington, DC. Special session on community pharmacy and patient safety, Thursday, May 3. For details and to register, visit:         www.npsf.org/congress/index.html.

    Join ISMP at the unSUMMIT! Bedside Barcode Technology in Practice, May 9-11.  Basic and advanced tracks and post-conference workshop by ISMP on using bar-code point-of-care data to drive quality improvement, monitor implementation progress, and enhance medication safety. For more information or to register, visit www.unsummit.com or call 412-287-5108.

  • Teleconference
  • Please join ISMP for a two-part teleconference entitled, “Smart Infusion Pumps: Strategies for Selecting, Implementing and Identifying Risk.” Part I will be held on June 6, 2007 from 1:30 to 3:00 PM ET and Part II will be held on June 21, 2007 from 1:30 to 3:00 PM ET. In Part I, ISMP’s Matt Grissinger and ECRI Institute’s Erin Sparnon will review errors that have been associated with the use of standard infusion pumps and discuss the technology behind smart pumps. In Part II, John Mitchell from the University of Michigan, will provide help from the perspective of a health system that has successfully employed smart infusion pump technology. Please visit www.ismp.org/teleconferences/tc2.asp to register for this teleconference.

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