The following are excerpts from the newsletter
- Should disciplinary action
be taken against those who make multiple or catastrophic
- Reducing medication errors becoming a priority for FDA
and pharmaceutical industry
- Safety Briefs
- Ambulatory care practitioners should exercise caution
when using estrogen/progestin combinations now that
Wyeth-Ayerst has added an additional combination with
a different strength of the progestin.
- Possible confusion between Testoderm® with Adhesive
and Testoderm TTS®?
- Ticlid® use has been linked to thrombotic thrombocytopenic
- Physician ordered generic kaolin/pectin as "Kaopectate®
30 mL via NG tube prn for loose stools". Nurse transcribes
the order as Kayexelate. Since the order included an
indication the error was caught.
- . There is no clear separation of nontoxic, toxic,
and lethal doses of colchicine. Make sure staff understands
the maximum doses.
- Reader suggests that orders requiring a decimal point
be written like a check to prevent errors. For example
an order for 1.4 mg would be written as one and four
tenths mg in parenthesis so that it would be harder
to confuse as 14 mg.
- Application deadline for the Bridge Medical Medication
Safety Management Fellowship at ISMP is April 30, 1998
- IV pump set free-flow: When
is enough enough?
- Agenda Items from January - March 1998 ISMP Medication Safety Alert!
- Safety Briefs
- Trissel's Handbook of Injectable Drugs 10th
edition now has caution statement about the potential
for fatal hemolysis and acute renal failure due to the
reduction in tonicity when sufficient sterile water is
used as a diluent for albumin.
- USP currently requires specific caution labeling with
the vinca alkaloid products vincristine (Oncovin®)
and vinblastine (Velban®). These two products require
warning labels on extemporaneously prepared syringes
that state "FATAL if given intrathecally. FOR IV USE
ONLY." In addition, the syringe must be placed into
an overwrap (accompanies manufacturer's container) which
also has this labeling. However, the package insert
for vinorelbine (Navelbine®), the other vinca alkaloid
available in the United States, requires only a warning
label that states "FOR IV USE ONLY." Although the mechanism
of toxicity for vinca alkaloid products administered
intrathecally has not been clearly defined, autopsies
on patients who received fatal doses of intrathecal
vincristine have demonstrated vast CNS tissue necrosis
and damage consistent with the dose limiting neurotoxicity
for all the vinca alkaloids. To date, no cases of intrathecal
administration of vinorelbine have been reported. To
prevent this from happening, we recommend that all extemporaneously
prepared syringes of vinca alkaloids, including vinorelbine,
be treated identically with label warnings and packaging
to act as barriers against intrathecal administration.
Such labels and overwraps are available in the packaging
of vincristine products. This concern has been forwarded
to the USP and FDA for review and action to require
consistent warning labels on all vinca alkaloid products
- FDA's Center for Devices and Radiological Health is
holding a live satellite video conference, "Natural
Rubber/Latex Allergy: Recognition, Treatment, and Prevention"
on May 5, 1998 from 1:00 to 4:15 p.m. EDT. A list of
viewing sites is posted on the World Wide Web at http://latex.fdli.org,
and a conference brochure can be ordered through the
FDA fax-on-demand system by calling 800-899-0381; push
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