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Back issues of the newsletter to January 1996 are available on CD-ROM.


august 14, 2008

  • Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning
  • Safety Brief: Fatal vindesine event.

    We’ve written about vinCRIStine errors many times, but any of the vinca alkaloids (vinBLAStine, vindesine, vinorelbine, and vinCRIStine) can cause fatal neurological effects if given via the intrathecal route instead of intravenously. Learn how to prevent these errors in your facility.

  • Safety Brief: Look-alike names.

    JANTOVEN
    (warfarin), JANUVIA (sitaGLIPtin), and JANUMET (sitaGLIPtin and metFORMIN) are similar names at risk for confusion. Read about recommendations for preventing name mix-ups with these and other medications with look-alike names.
  • Safety Brief: Get parents involved to prevent vaccine errors.

    This past week, we received three separate reports that described vaccine errors in which children received incorrect vaccine products in their pediatrician’s office. Discover safeguards you can implement in your facility.

  • Safety Brief: New osteoporosis guides.

    A pair of new guides from the Agency for Healthcare Research and Quality (AHRQ) draws from unbiased scientific evidence to compare the
    benefits, risks, and costs of osteoporosis treatments. Find out more about them in the newsletter.
  • Worth Repeating: EPINEPHrine-ePHEDrine mix-ups

    We received a report of another mix up between ePHEDrine and EPINEPHrine. Understand more about our efforts to prevent further confusion and what safety measures you can implement in your facility.

Special Announcements

  • The ISMP Cheers Awards are one of the most prestigious ways to recognize innovators in the field of patient safety. The awards honor individuals, hospitals, health systems, community pharmacies, or companies that have made extraordinary advances in medication safety in the past year. Nominations will be accepted until September 12, 2008.
    Nominations also are being accepted for the 2008 ISMP Medication Safety Alert! Subscriber Award, which honors an organization that widely distributes the ISMP newsletters and uses the information to reduce the potential for medication errors. The awards acknowledge excellence in all areas of healthcare, including acute, long-term care, home care, and community settings. Nominations are welcomed from physicians, pharmacists, nurses, administrators, and allied health professionals. Self-nominations are strongly encouraged.
    Winners receive an award, national recognition for their work, and a travel stipend to attend the annual ISMP Cheers Awards gala dinner on December 9, 2008.  Peter B. Angood, MD, FRCS(C), FACS, FCCM, Vice President and Chief Patient Safety Officer, The Joint Commission, and lead for the international World Health Organization’s Collaborating Center for Patient Safety Solutions will be the Keynote Speaker. To submit a nomination online, go to: www.ismp.org/Cheers.
    The ISMP Cheers Awards would not be possible without the generous support of committed sponsors. We need your help to continue spotlighting heroes and trendsetters in the prevention of medication errors. Consider helping to ensure the future of the awards and the continuation of ISMP’s lifesaving work by making a donation.
  • Take our survey. ISMP is conducting a survey on smart infusion pumps. If you use smart pumps, please have the individual most knowledgeable about current use of the pumps complete the survey located at: www.ismp.org/survey/Survey200806.asp by September 5, 2008.
  • Maximize the effectiveness of your medication safety team! ISMP will hold a two-part teleconference series to help healthcare organizations meet the challenges involved with creating and maintaining a successful medication safety team, including establishing a joint accountability model, determining the role of a physician leader, and using data and external information to effect change. This dynamic two-part teleconference series will be offered on September 17, 2008 and October 23, 2008 at 1:30 pm (ET). For details, visit: www.ismp.org/educational/teleconferences.asp.
  • ISMP 2008- 2009 Fellow. Please join us in welcoming our 2008- 2009 ISMP Safe Medication Management Fellow, Michelle M. Bell, RN, BSN. The fellowship is supported by a grant from Cardinal Health Foundation. Michelle received her BSN from Creighton University in Omaha, NE. She comes to ISMP from Alegent Health Bergan Mercy Medical Center, a 400-bed hospital in a nine hospital healthcare system, with experience in emergency nursing and, most recently, performance improvement. For information about the fellowship go to: http://www.ismp.org/profdevelopment/managementfellowship.asp.

august 28, 2008

  • Misprogramming PCA concentration leads to dosing errors
  • Safety Brief: Communicate alteplase dose and indication.
    ACTIVASE (alteplase) and of CATHFLO ACTIVASE (alteplase; available in 2 mg lyophilized powder vials) can be confused if the abbreviation tPA is used, especially when communicated without an indication. Discover ways to prevent mix-ups in your organization.
  • Safety Brief: Don’t use empty pre-labeled syringes/bowls.
    ISMP and The Joint Commission are proponents of labeling syringes and bowls. Labels should never be applied to syringes or basins in advance of medication/solution preparation, nor should they be prelabeled before preparation. Learn more about practice recommendations and potential problems with syringe labeling.
  • Message in our mailbox: Stocking Different Concentrations
    We recommend separating products that come in standard and concentrated forms. A reader suggested also using shelf-talkers (shelf-labels) if this step is used in your pharmacy. Read more about his suggestion.
Special Announcements
  • The ISMP Cheers Awards are one of the most prestigious ways to recognize innovators in the field of patient safety. The awards honor individuals, hospitals, health systems, community pharmacies, or companies that have made extraordinary advances in medication safety in the past year. Nominations will be accepted until September 12, 2008.
    Nominations also are being accepted for the 2008 ISMP Medication Safety Alert! Subscriber Award, which honors an organization that widely distributes the ISMP newsletters and uses the information to reduce the potential for medication errors. The awards acknowledge excellence in all areas of healthcare, including acute, long-term care, home care, and community settings. Nominations are welcomed from physicians, pharmacists, nurses, administrators, and allied health professionals. Self-nominations are strongly encouraged.
    Winners receive an award, national recognition for their work, and a travel stipend to attend the annual ISMP Cheers Awards gala dinner on December 9, 2008.  Peter B. Angood, MD, FRCS(C), FACS, FCCM, Vice President and Chief Patient Safety Officer, The Joint Commission, and lead for the international World Health Organization’s Collaborating Center for Patient Safety Solutions will be the Keynote Speaker. To submit a nomination online, go to: www.ismp.org/Cheers.
    The ISMP Cheers Awards would not be possible without the generous support of committed sponsors. We need your help to continue spotlighting heroes and trendsetters in the prevention of medication errors. Consider helping to ensure the future of the awards and the continuation of ISMP’s lifesaving work by making a donation.
  • Take our survey. ISMP is conducting a survey on smart infusion pumps. If you use smart pumps, please have the individual most knowledgeable about current use of the pumps complete the survey located at: www.ismp.org/survey/Survey200806.asp by September 5, 2008. Maximize the effectiveness of your medication safety team! ISMP will hold a two-part teleconference series to help healthcare organizations meet the challenges involved with creating and maintaining a successful medication safety team, including establishing a joint accountability model, determining the role of a physician leader, and using data and external information to effect change. This dynamic two-part teleconference series will be offered on September 17, 2008 and October 23, 2008 at 1:30 pm (ET). For details, visit: www.ismp.org/educational/teleconferences.asp

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