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The following are excerpts from the newsletter


December 3, 1997

  • MIME and MINE: Safety problems posed by investigational drug name abbreviations and acronyms
  • Phenylpropanolamine and myocardial injury: a serious ADR not appreciated by consumers.
  • Multiple tablet issue revisited
  • Safety Briefs
    • Pharmacia and Upjohn recommend that off-label use of recombinant somatropin (Genotropin® for tratment of acute catabolisn be stopped.
    • Knoll Pharmaceutical will soon be launching Meridia® (sibutramine)to help obese patients lose weight. It sounds similar to Aredia® (pamidronate) a bone resorption inhibitor used in Paget's Disease.
    • Data from 124 cases of seizures in patients taking the opioid analgesic Ultram®(tramadol) reported by FDA.
    • Special Alert about pediatric death due to cisplatin overdose draws comment form ISMP Senior Consulting Scientist Dr. John Senders. He said of warnings "many people do not read them; many of those that read them do not really comprehend them; and many of those that comprehend them do not obey them." The Special Alert called for added insttutional safety systems.
    • FDA announces new rules about labeling of unit dose packages of drugs and vitamin supplements containing 30 mg or more of elemental iron.
    • Need for clarity in orders demonstrated by confusion of "Z-Pack" with ice pack.
    • What else could be wrong in this order? Cerebyx® (fosphenytoin) orders often require follow-up to prevent mistakes.

December 17, 1997

  • JC Accreditation Watch policy changes
  • Confusion confession!
  • Safety Briefs
    • FDA issues Public Health Advisory advising health professionals to monitor patients receiving low molecular weight heparins or heparinoids.
    • FDA releases background article on the protease inhibitors.
    • Nurse who administered oral medications intravenously is not prosecuted under criminal charges but has nursing license revoked.
    • Gilead Sciences announces expanded access progran for investigationl, oral once-dail revers trnascriptase inhibitor, Preveon. Generic name is nearly identical to another product. Suggested to use Brand name when reffering to this drug.
    • London, England pharmacist points out abbreviations in some counties are different and may cause confusion.
    • An article on New York State Nurses Association web site claims that the Nursing Association has found a possible link between nurses who work in downsized facilities and the number of medication errors committed.
  • Important end of year announcements:
    • ISMP Industry seminar
      APril 3,1998 seminar for pharmaceutical industry executives and other professional who work in marketing, legal, advertising, regulatory affairs and quality assurance. The purpose of the seminar, which will be held in Princeton, NJ, is to promote the development of safe pharmaceutical trademarks as well as safe pharmaceutical product labeling, packaging, and advertising. Faculty will include ISMP staff and board members as well as industry experts and international regulatory affairs authorities. For more information, contact ISMP's Susan Proulx, Pharm.D., at 215 947 7797, or e-mail sproulx@ismp.org
    • ISMP announces medication safety fellowship
    • IHI collaborative on adverse drug events
      The Institute for Healthcare Improvement will launch a second Breakthrough Series Collaborative on Reducing Adverse Drug Events and Medical Errors in February, 1998. For further information, call IHI at 617 754 4825.
    • ACPE Credit available for pharmacists
      We are pleased to announce that, beginning with our first issue in January, pharmacists who read the ISMP Medication Safety Alert! may, after completing appropriate examination questions and registration materials, earn two (2.0) contact hours of continuing education accredited by ACPE. This program is made available through the University of Arkansas College of Pharmacy. A nominal fee will be charged for the credits, which will be awarded quarterly. We also hope to make nursing and physician CE credits available in the coming year. We will provide more information in January

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