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The following are excerpts from the newsletter

April 7,1999

  • 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 alcohol reported.
    • 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
    • ISMP has several new, colorful, medication safety posters

April 21,1999

  • 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 NBC.
    • 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

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