The following are excerpts from the newsletter
- Accidental childhood acetaminophen
overdoses illustrate our responsibility to educate parents
- Different dosage forms of same drug may not share the
same monograph in PDR: Anyone who regularly uses the
Physicians' Desk Reference (PDR) knows that every drug is
not listed in this reference. The PDR does include drug
manufacturers official product inserts. Like product inserts,
certain information is hard to find, which could lead to
- FDA drafts guidance on labeling of plastic vials:
On July 26, FDA issued a Federal Register notice about the
availability of a draft guidance for industry entitled,
"Inhalation Drug Products Packaged in Semipermeable
Container Closure Systems." This is intended to provide
guidance on inhalation drug products that are packaged in
semipermeable primary container closure systems. We hope
that you will take the time to submit written or electronic
comments on the draft guidance by October 24, 2002 at http://www.fda.gov/cder/guidance/4168dft.PDF.
- Safety Briefs
- Most hospital emergency rooms use the Broselow Tape
during pediatric emergencies. A specific color zone
is determined by stretching the tape out from head to
toe alongside the supine child. This color zone is used
to correlate pre-calculated dosages and volumes of emergency
medications, fluids, and equipment sizes based on the
child's height. Pharmacy oversight is needed to assure
that proper strengths of medications are available for
emergency use with the Broselow Tape.
- A dermatologist gave what he thought was a sample
30 g tube of PROTOPIC (tacrolimus) Ointment 0.1% to
a 17-year-old female patient, telling her to apply it
for treatment of facial contact dermatitis/eczema. The
patient applied it as directed over her facial rash.
Imagine her surprise when the contents turned out to
be nothing more than ink from a felt tip pen!
- We have several reports of mix-ups between the anticonvulsant,
TOPAMAX (topiramate), and the beta-blocker, TOPROL XL
- It's not what you say, it's the way you say it. An
ICU patient admitted for chest pain mentioned that her
physician previously had given her a prescription for
nitroglycerin tablets, but she never took them despite
substernal pain. The patient said, "My pharmacist
told me he hoped that I never have to take this medicine
because it will probably give me a big headache."
- There's an FDA approved prescription vitamin product
called DIATX, which is indicated for the nutritional
requirements of patients under a doctor's care for end
stage renal failure, dialysis, hyperhomocysteinemia,
or inadequate dietary vitamin intake. However, there
is another trademarked product called DIATEX, which
is diazepam in Mexico.
- The road less traveled
- "40 of K" is not OK - A physician was
performing a procedure in a cardiac catheterization lab
when he gave a verbal order for "40 of K" for
a patient in CCU. The facility had a policy that verbal
orders must be repeated back and verified, so the nurse
repeated back exactly what she had heard, "40 of K."
However, she transcribed the order in writing as "40
mg of IV Vitamin K now."
- Safety Briefs
- A pharmacy technician was preparing two doses of pamidronate
90 mg for IV infusion. She reached into the product's
storage bin and picked up two vials, one of pamidronate
90 mg and another of etomidate 40 mg (2 mg/mL, 20 mL)
that looked nearly identical. Both products were distributed
by Bedford Laboratories and packaged in gray and white
vials and cartons.
- The two top manufacturers of insulin products, Novo
Nordisk and Eli Lilly, both recommend discarding insulin
vials kept at room temperature after one month. This
recommendation may not conform to policies in some hospitals
that allow use of multiple dose insulin vials up to
the manufacturer's expiration date.
- The Texas State Board of Pharmacy strongly encourages
use of the ISMP Medication Safety Self Assessment
tools. So strongly that they allow three hours of continuing
education credit for completion of either the hospital
or community pharmacy version.
- Similar names and strengths contributed to a pharmacist
misreading an order for ZYVOX (linezolid) 600
mg BID as ZOVIRAX (acyclovir) 600 mg BID.
- One patient experienced severe burning in her eyes
and blurred vision when she instilled what she thought
was eye drops. A co-worker took the bottle from her
and saw the very small notation on the label: "For
dermatological use only. Not for ophthalmic use."
The bottle was a professional sample of ELOCON
(mometasone) 0.1% lotion which contains 40% isopropyl
- An RN who works in patient safety wrote to tell us
about sample packages of CELEBREX (celecoxib)
that she received recently from her rheumatologist along
with a prescription for Celebrex 200 mg BID. The outside
carton of each sample pack states "Celebrex 200
mg." This made her think that each package contained
200 mg. But when she opened the box, there were 3 capsules
on a blister card that also stated "200 mg."
- Serious potential for a mix-up exists with methotrexate
injections labeled by Immunex Corporation. Although
the label color schemes vary for the preservative-free
(purple, blue, white) and the preservative containing
vials (red, blue, white), this difference is not very
obvious when vials are removed from their cartons and
the caps snapped off.
- A hospital's HIV post-exposure prophylaxis protocol
was recently changed to include nelfinavir (VIRACEPT)
instead of indinavir (CRIXIVAN). So recently,
when an employee needed post-exposure prophylaxis, a
pharmacist wanted to give her the first dose before
the prescription was ready for pick-up. Unfortunately,
she grabbed nevirapine (VIRAMUNE) instead of