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The following are excerpts from the newsletter


December 1, 1999

  • Dose confusion with phosphorus containing products
  • Endo is modifying PERCOCET nomenclature
  • Safety Briefs
    • Mg (magnesium) can be mistaken for MS (morphine sulfate).
    • Confusion can occur between edetate calcium disodium (CALCIUM DISODIUM VERSENATE) which is used for lead poisoning and edetate disodium (ENDRATE; DISOTATE) which is used for emergency treatment of hypercalcemia.
    • FDA posts drug warnings

    • 1. Potential effects of VIRAMUNE (nevirapine) in patients on methadone maintenance.
      2. Bristol-Myers Squibb Oncology/Immunology revised the boxed warning about fatal and nonfatal pancreatitis occurring with VIDEX (didanosine;ddI)
      3. Wyeth-Ayerst issued warnings about changes made in label warnings for RHEUMATREX (methotrexate).
    • Since publication of our November 3, 1999, article about IV penicillin G during alternatives during the shortage, we learned about the availability of penicillin G potassium in 1, 2 and 3 million units per 50 mL minibags from Baxter Healthcare (Round Lake, IL 60073).
    • Two products with the same exact pronunciation! LAMICEL, an osmotic cervical dilator and LAMISIL (terbinafine), an antifungal agent. Orders should not be accepted if the route of administration and indication is not specified.
    • An excellent literature review of psychoactive-drug-induced cutaneous reactions has been published, which includes reference tables listing each drug and the associated skin reactions (Kimyai-Asadi A et al. Critical review: adverse cutaneous reactions to psychotropic medications. J Clin Psychiatry 1999;60:714-25).
    • On Monday evening, the Institute of Medicine (IOM) published its report on preventing death and injury from medical errors. The report lists groundbreaking recommendations including significant support for improving national reporting of medical errors. Dr. Linda Kohn, coauthor of the IOM report, will be the keynote speaker at the second annual ISMP Cheers Awards Dinner. Call us immediately at 215-947-7797 if you would like to attend.

December 15, 1999

  • New millennium brings great promise and support for reducing medication errors
  • 1999 medication safety "cheers" but no "jeers"
  • Safety Briefs
    • Practitioners should alert patients to problems with improper suspension of NPH insulin in pen devices and assure that proper mixing technique is demonstrated.
    • A correction is needed in the phenobarbital sodium monograph in Mosby's 1999 Intravenous Medications (Gahart B. Nazareno A.; 15th edition, page 671). The correct loading dose is 10 to 20 mg per kg.
    • PERCOCET products are available in the following combinations of oxycodone/acetaminophen: Percocet 2.5/325; 5/325; 7.5/500 and 10/650. Some strengths were listed incorrectly in last week's issue.
    • In our February 11, 1998, issue, we mentioned the potential for confusion between PROLEUKIN (aldesleukin), for metastatic renal cell carcinoma, and the platelet growth factor product, NEUMEGA (oprelvekin). We now have two reports where hospitalized patients received Proleukin rather than Neumega when physicians' prescriptions for "IL-11" were misinterpreted as IL-2.
    • A physician's order for ATACAND (candesartan cilexetil) was misread by a nurse as "antacid."
  • Announcements
    • A complete set of back issues (Volumes I-IV) of the ISMP Medication Safety Alert! is now available on CD-ROM for $75. The material is presented in Adobe PDF format with the Adobe Acrobat Reader included. All articles are completely searchable in full text and may be copied electronically for use in internal newsletters, committee reports, etc. Purchase orders and major credit cards are accepted
    • ISMP announces the availability of the 2000-2001 Safe Medication Management Fellowship. The one-year program trains a nurse, pharmacist, or physician in methods for preventing adverse drug events. The fellow works closely with ISMP staff on a variety of educational activities and visits various practice sites, regulatory agencies, and pharmaceutical manufacturers. Fellowship applicants must have at least one year of clinical experience. A syllabus and directions for application can be requested by contacting us at 215 947 7797 or by e-mailing us at

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