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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

April 10, 2008

  • FDA Advise-ERR: Medication errors associated with Cerebyx
  • ISMP Quarterly Action Agenda January - March 2008
  • Safety Brief: Consumer safety with creams and ointments
  • FDA published consumer health information to call attention to risks associated with application of over-the-counter topical products. Read this Safety Brief to identify products known to have caused harm when used incorrectly.

  • Safety Brief: Fougera ointment mix-ups.
  • PETRALUBE, a petrolatum ophthalmic ointment, and erythromycin ophthalmic ointment, both from Fougera, have been confused for one another.  Look-alike packaging is a contributory factor. This Safety Brief details the circumstances surrounding the reported mix-ups and offers ways to prevent similar events in your facility.

  • Weird happening.
  • This month, Google searches for “CEREBYX” (fosphenytoin) returned sponsored links for CELEBREX (celecoxib), a finding that reinforces the erroneous perception that these sound-alike agents are the same. 

  • Message in our mailbox: Wireless refrigerator monitoring
  • In response to an item in our January 17, 2008 Medication Safety Alert, a reader shares multiple positive benefits after implementing electronic refrigerator monitoring in a large facility.

Special Announcements…

  • ISMP teleconference.

    Important Design Considerations for Safe Packaging and Use of Pharmaceutical Products, a unique teleconference designed for individuals in clinical practice settings and the pharmaceutical industry, will be held on May 7, 2008 from 1:30 to 3:00 p.m.  Please join human factors expert John Gosbee, MD, MS and ISMP’s president, Michael Cohen, RPh, MS, ScD, to learn how packaging impacts safe use of medications. To register, visit: www.ismp.org/educational/teleconferences.asp.

  • ADC guidelines.

    The final guidelines for safest use of Automated Dispensing Cabinets can be found at: http://www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf. The guidelines address screen information, inventory control, restocking process, overrides, transport of medications removed from cabinets, and more.

April 24, 2008

  • Some red rules shouldn’t rule in hospitals.
  • Safety Brief: Caution regarding color-coded eye meds.
  • Color-code schemes used for ophthalmic products result in  problematic look-alike mix-ups.  This brief shares a mix-up involving vials of Bausch and Lomb’s cyclopentolate 1% and atropine sulfate 1% and describes barriers to remedying the problematic packaging.

  • Safety Brief: Lexi-Comp notice.
  • Lexi-Comp asked us to convey important information regarding overdose/toxicology information in some Lexi-Comp printed publications. This brief links you to Lexi-Comp’s errata.

  • Strength misread as total dose.
  • After receiving a telephone request for "mannitol IV" for a patient in the emergency department (ED), the pharmacy dispensed several 250 mL bags of mannitol 20% (B. Braun). Loose order communication processes coupled with confusing labeling led to a near miss overdose in the ED.  Read this brief to learn proactive strategies to decrease the likelihood of a similar mishap in your facility.

Special Announcements…
  • ISMP teleconference.
    Important Design Considerations for Safe Packaging and Use of Pharmaceutical Products, a unique teleconference designed for individuals in clinical practice settings and the pharmaceutical industry, will be held on May 7, 2008 from 1:30 to 3:00 p.m.  Please join human factors expert John Gosbee, MD, MS and ISMP’s president, Michael Cohen, RPh, MS, ScD, to learn how packaging impacts safe use of medications. To register, visit: www.ismp.org/educational/teleconferences.asp.

  • Free audio CE available.
    ISMP is now offering two audio continuing education (CE) presentations on the successful implementation and safe use of current medication dispensing technologies, including automated dispensing cabinets (ADCs), carousels, packagers, bar coding software, and bedside verification using bar code scanning. Pharmacists can earn free CE credits by listening to the presentations and completing online tests. To access the CE presentations, visit: www.ismp.org/profdevelopment/continuingeducation.asp.

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