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The following are excerpts from the newsletter

  • The reports are in…or are they? Awareness of medication error reporting programs needs a boost
  • Don't lose track of orders during clarification - Errors of omission can occur when therapy is unnecessarily delayed because of efforts to clarify an order. A recent report sent to ISMP provided an example.
  • Safety Briefs
    • Use caution when reconstituting SYNAGIS (palivizumab), a monoclonal antibody used to prevent respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients.
    • A physician had prescribed LEVOXYL (levothyroxine) 1 tab po q day," but the "q" was misread as a 5" and the medication was dispensed with directions to take "1 tab 5 days each week."
    • Look-alike names and packages are at the root of most stocking errors in automated dispensing cabinets. ISMP has received reports with products that have been problematic lately.
    • Worth Repeating - We've just learned about another fatal error involving inadvertent administration of vincristine intrathecally.
    • Medication safety videos available free via the Internet - Since February 2002, FDA has been producing an excellent monthly series of patient safety videos that can be viewed on the web. Included among the many topics each month are reports of medication errors provided by ISMP or the Division of Medication Errors and Technical Support in FDA's Office of Drug Safety. Recent issues include alerts on drug name confusion between TAXOTERE (docetaxel) and TAXOL (paclitaxel), methemoglobinemia from anesthetic sprays (both January 2003), and methotrexate overdoses (February 2003). Any computer with Internet access can be used to view the programs, which are available through the ISMP or FDA web sites).
    • Bar-coding teleconferences - Help 'raise the bar' in healthcare by getting ready for barcoding. Get your multidisciplinary team together for a four-part teleconference series designed to explore: what bedside bar-coded drug administration entails how it can benefit patients and providers how to best prepare for this technology to maximize its advantages what barriers effect successful implementation what systems are available from major vendors The four-part teleconference series will be held on April 3, 8, 17, and 24, from 1:30-3:00 p.m. Eastern Time. Faculty includes: Michael Cohen, RPh, MS, ScD, and Judy Smetzer, RN, BSN, from ISMP; Mark Neuenschwander, president of The Neuenschwander Company, a leading technology and automation consulting organization; Steve Rough, MS, director of pharmacy at the University of Wisconsin Hospital and Clinics, where a bar-coding system has been implemented; and Chris Tucker, RPh, who heads the Bar Code Medication Administration project for the US Department of Veterans Affairs.
    • Medication Safety Fellowship - If you desire a career as a medication safety specialist, there's no better way to prepare than to serve a full-time, one-year fellowship with ISMP in Huntingdon Valley, PA. The ISMP Safe Medication Management Fellowship, now in its 10th year, gives an experienced health professional an unparalleled opportunity to work and travel with ISMP staff to gain knowledge and experience related to improving medication safety. Extensive networking capabilities also will be developed with the nation's leading safety authorities in the pharmaceutical, healthcare, and legislative and regulatory communities. Graduates of the program now are employed in full-time medication safety positions at ISMP, FDA, and other healthcare systems. Call 215-947-7797 or send a message to us to request a syllabus and application. Applications will be accepted until March 31, 2003.

February 20, 2003

  • It’s time for standards to improve safety with electronic communication of medication orders
  • Sometimes things get lost in the translation - Although US Census Reports estimate that 19 million people are limited in English proficiency, little is known about the frequency and potential consequences of errors related to misinterpretation of medical information.
  • Worth Repeating - Prescribers should always clarify the purpose of each medication with patients and include it on prescriptions, especially if the drug has multiple uses or is being used “off-label.”
  • Bar-coding teleconferences - If your medication safety team has been talking about the use of a bar-coded drug administration system as one of your approaches to reduce medication errors, consider joining us for a series of live teleconferences presented on April 3, 8, 17, and 24. Along with several nationally recognized experts, we’ll provide independent, objective information about currently available bar-code systems, assessment of readiness, implementation strategies, tips and time savers, what works and what doesn’t, and much more. Visit our web site to register and for additional information on topics and speakers for each program. It’s an important conference series you won’t want to miss.
  • Safety Briefs
    • Last week, Bristol-Myers Squibb (BMS) revealed that it will distribute a Serzone patient information leaflet with each prescription to encourage patients to use the tablet’s appearance to confirm that it is Serzone. Both BMS and AstraZeneca, manufacturer of Seroquel, also encouraged healthcare providers to report medication errors with these products to USP, ISMP and FDA.
    • In Washington last week, the House Committee on Energy and Commerce approved the Patient Safety and Quality Improvement Act of 2003.
    • Looking for innovative ways to think about issues in pharmacy job performance, satisfaction, and patient safety? An excellent series of self-study modules, developed by Anthony Grasha, PhD, University of Cincinnati, that integrate the role of human factors in the practice of pharmacy can be found at
    • Nursing Matters - ISMP is excited to announce that we will be publishing a newsletter written especially for front-line nurses. Called the ISMP Medication Safety Alert! Nursing Matters, this monthly, two-page newsletter will be offered free to nurses during 2003 through a unrestricted grant by Eli Lilly and Company used to fund the start-up of this important publication. While the drug safety issues covered in the ISMP Medication Safety Alert! Acute Care edition are certainly applicable to nurses, anecdotal evidence suggests that crucial medication safety information may not be reaching very busy front-line nurses who are continuously overwhelmed with information related to a wide variety of important issues. Through its unique design, it’s anticipated that nursing matters will be just the vehicle needed to deliver medication safety information to nurses who administer medications. To determine its success, we will be using focus groups and surveys to evaluate the interest, value, and impact of nursing matters, and the best way to distribute important medication safety information to nurses in the future. ISMP plans to distribute the monthly newsletter by e-mail to a single nursing representative in each hospital or health system, who will take responsibility to distribute the newsletter to all front-line nurses in the organization. Please have a representative from your hospital or health system visit our web site to subscribe to this free publication.

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