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The following are excerpts from the newsletter

December 4, 1996

  • Case update: epinephrine death in Florida.
  • Phenylpropanolamine and myocardial injury: a serious ADR not appreciated by consumers.
  • CDC reports Varivax® vaccine errors.
  • Safety Briefs
    • October issue of ECRI's Risk Management Reporter contains two article abstracts describing central venous catheter mishaps.
    • From our "Tips for Parents Department"... mark the level of the liquid in the bottle.
    • USP joins fight against Potassium Chloride errors.
    • Clintec Nutrition Co. changes labeling of 70% Dextrose containers.
    • Another fosphenytoin dispensing error.
    • Correct computer systems listing of fosphenytoin concentration to avoid possibility of incorrect labels.

December 18, 1996

Influenza Vaccine Special Alert

December 18, 1996

  • Action may be necessary to prevent confusion between Roxanne's oral liquid opiate products
  • Ideal body weight should be considered when calculating Paraplatin® doses in obese patients/
  • Safety Briefs
    • Abbot Laboratories moves to reduce errors with morphine PCA syringes
    • Neuenschwander Co. of Redmond Washington publishes market comparison of automated dispensing technologies. Phone:(206)868-5035 E-mail
    • Protocol for preventing fosphenytoin confusion available from ISMP
    • Additional reports of confusion due to similarity of names of Humalog® and Humulin® N in elderly patients with poor eyesight.
    • Prescription for Claritin-D® 24 almost filled with 24 tablets of Claritin-D® rather than the Claritin-D 24 hour.
    • Order written for Insulin as 6U almost given as 60 Units. Don't abbreviate the units when writing orders to prevent confusion.
    • NPH insulin contaminated with Heparin turns the suspension clear.
    • FDA notifies MedWatch of a series of injuries in patients undergoing dialysis when cellulose acetate dialysers were used

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