The following are excerpts from the newsletter
- Errors and near misses prompt warning to practitioners
and a call to rename CELEBREX
- The "five rights"
- Safety Briefs
- Special precautions needed with Actiq®
a new oral transmucosal fentanyl citrate product.
- Error in reconstitution of Amoxil with external use
- Add consideration of error potential to review by
P&T Committee when adding new drugs to a formulary.
- Even with exquisite handwriting adding orders after
the fact may cause confusion.
- A comprehensive medication error taxonomy has been
created by the National Coordinating Council on Medication
Error Reporting and Prevention. It is available at http://www.nccmerp.org/pdf/taxo2001-07-31.pdf
- ISMP has several new, colorful, medication safety
- The check, please!
- ISMP Action Agenda
- Safety Briefs
- When involved in an error, an individual's stress
level may cause another error when giving an antidote.
- Send medication error reports directly to the USP-ISMP
Medication Error Reporting Program (MERP). Reports sent
to pharmaceutical companies may not be forwarded to
the USP, FDA or ISMP, but companies whose products are
in some way involved in medication errors will receive
reports from the USP-ISMP MERP.
- ISMP is actively involved in alerting practitioners
and consumers to name-related issues surrounding CELEBREX
(celecoxib), CEREBYX (fosphenytoin) and CELEXA (citalopram).
Quotes are appearing in the news media including Dateline
- At the ASHP Annual meeting in Reno, ISMP will present
a symposium on combining mobile computerized physician
order entry, automated dispensing and automated drug
administration as a means of reducing medication errors.
- Don't wait for a sentinel event to do root cause analysis.
Use it now as a tool for "near misses"
to improve medication processe