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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

february 12, 2009

  • Follow ISMP Guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)


  • HazardAlert: Reuse of insulin pen for multiple patients risks transmission of bloodborne disease

    A US Army hospital publicly announced last week that 2,114 insulin-dependent diabetic patients admitted between August 2007 and January 2009 may be at risk for developing a bloodborne disease because of incorrect procedures used during the administration and sharing of insulin pen devices. Facilities using insulin pens should act immediately and provide education and continuous monitoring to prohibit situations where an individual patient’s pen might be reused for another patient.
  • Safety Brief: Color-coded eye meds.

    Bausch and Lomb’s atropine sulfate 1% and cyclopentolate 1% ophthalmic drops look nearly identical, which led to a drug selection error when filling an automated dispensing cabinet. These products use a color-coding scheme based on therapeutic class. Despite ISMP’s efforts to convince AAO, FDA, and manufacturers that color-coding leads to errors, no changes have been made to improve safety. Possibly the best way to prevent problems is to avoid awarding contracts to one vendor for an entire product line, and purchase drugs within a class from different manufacturers.

  • Safety Brief: Metoprolol extended-release shortage and dosing errors.

    The current metoprolol succinate extended release tablet shortage may be contributing to medication errors. A hospital pharmacist recently told us that they often see patients who list metoprolol extended-release tablets on their drug history. However, because of the shortage, their pharmacy or pharmacy benefits manager (PBM) may have recently switched them to the immediate-release product, metoprolol tartrate.
    Metoprolol tartrate is usually taken twice a day, while the extended-release product is taken just once a day. Some patients, without realizing it, may be taking the immediate-release drug just once a day, like they took their extended-release product.
Special Announcements
  • Patient Safety Awareness Week. March 8-14, 2009, is the time established by the National Patient Safety Foundation to celebrate Patient Safety Awareness Week (www.npsf.org/hp/psaw/). To help celebrate this year’s theme— A Prescription for Safety; One Partnership, One Team—ISMP is offering a 40% discount (while supplies last) on two videos you can broadcast in your facility for patients, visitors, and staff to view: Patients
  • Play a Vital Role in Patient Safety and Patient Safety Requires a Team Effort. To place an order, visit: http://onlinestore.ismp.org/shop/. We also encourage you to invite your patients, visitors, and staff to visit ConsumerMedSafety.org, our new consumer website (www.consumermedsafety.org), and to sign up for free, personalized drug safety alerts.
  • ISMP teleconference. Join ISMP and our guest speakers from Brigham and Women’s Hospital and the Cleveland Clinic for our next teleconference, Enhancing Medication Safety: The Role of Safe Labeling, Bar Coding, and Outsourcing of IV Products,on March 12, 2009. You will learn how product labeling, bar-coding technology, and outsourcing IV products can reduce the potential for adverse drug events with IV products. For details, please visit: www.ismp.org/educational/teleconferences.asp.
  • ISMP Safe Medication Management Fellowship. This yearlong learning opportunity, funded by Cardinal Health Foundation, offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. Fellows have the unique opportunity to make a real difference in medication safety. Fellowship information and application can be found at: www.ismp.org/profdevelopment/managementfellowship.asp. Applications can also be requested by calling 215-947-7797 or via mbell@ismp.org. All applications must be received by March 31, 2009.
  • ISMP Medication Safety Intensive. This intensive workshop will help you look at your organization “through the eyes of ISMP” medication safety experts, who will take you though their real-world experiences in establishing and evaluating medication safety programs. Three dates are scheduled in 2009, and space is limited. For more information about the program and to register, please visit: www.ismp.org/educational/MSI.
  • Joint Commissionnot counting NPSG 8 (Medication Reconciliation) during 2009 surveys - http://www.jointcommission.org/Library/WhatsNew/med_rec.htm
  • FDA moving toward new requirements for safe prescribing of certain opiates, including transdermal fentanyl and morphine and oxycodone extended release oral - http://www.fda.gov/cder/drug/infopage/opioids/default.htm

february 26, 2009

  • Inattentional blindness: What captures your attention?

  • Unusual explanation for hyperglycemia in patients on insulin

    Clinic nurses discovered that some patients were experiencing hyperglycemia after discharge from the hospital. The culprit? Patients who became familiar with the NovoFine Autocover (safety needle) while in the hospital were later confused as they began to use a standard BD pen needle (BD Ultra-Fine III) after discharge. For more information and photographs of the needles, see the newsletter.

  • Safety Brief: “2day” gets “86ed.”

    An order for SLOW-MAG (magnesium chloride), misspelled as “Slomag,” 64 mg TID “2Day,” was received by a pharmacy. The pharmacist questioned whether this meant to give the medication TID for 2 days (her initial thought) or give it just “today” (2Day). She called to clarify the order, and it turned out that “2Day” was “text messaging” shorthand for “today.” The pharmacist asked the nurse to rewrite the verbal order and politely suggested that text messaging language was not appropriate for transcribing medical orders due to potential misinterpretation. Using text messaging abbreviations with medical orders is a new and evolving chapter in the dangerous abbreviations saga. Learn more about dangerous abbreviations on our website www.ismp.org.

  • Safety Brief: Product stability for “off label” drug storage.

    ASHP has a new resource on their website with information on the stability of refrigerated and frozen drugs when not stored according to product labeling. According to ASHP, “It provides useful guidance for emergency preparedness, utility or equipment failure, and improper storage during shipping.” The reference, Stability of Refrigerated and Frozen Drugs, is available on the Patient Safety Practice Resource Center page under “Recommended Reports” (provided with permission by The Pharmacist’s Letter.)

  • Safety Brief: Confusing nomenclature.

    Valproic acid nomenclature can be a little confusing. There are various dosage forms and salts available, so it’s easy to understand how products can be confused.
    You can find additional tips on preventing confusion between these products in our current newsletter and the February 7, 2001 issue (www.ismp.org/Newsletters/acutecare/articles/20010207-1.asp).

  • Safety Brief: Enteral Nutrition Practice Recommendations from A.S.P.E.N.

    A new comprehensive document is available on the American Society for Parenteral and Enteral Nutrition’s (A.S.P.E.N.) website, www.nutritioncare.org/safety, for healthcare teams who are involved in the delivery of enteral nutrition, including clinicians, educators and researchers, and patients and their caregivers.
    The recommendations, which were developed by an interdisciplinary taskforce, deliver information that will lead to more successful enteral nutrition practices. Recommendations will also be published in the March-April 2009 issue of the Journal of Parenteral and Enteral Nutrition. A bound copy can also be purchased through: www.nutritioncare.org.
  • Safety Brief: Vaccine abbreviations.

    The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) has provided a current list of standardized abbreviations for vaccines included in the immunization schedules for children, adolescents, and adults (www.cdc.gov/vaccines/recs/acip/downloads/vac-abbrev.pdf).
    However, ISMP discourages the use of vaccine abbreviations (or any drug name abbreviation) when communicating prescription information because some abbreviations on the CDC list have been confused with one another. For more information about preventing confusion between confused drug names, visit our website www.ismp.org.
Special Announcements
  • Patient Safety Awareness Week. March 8-14, 2009, is the time established by the National Patient Safety Foundation to celebrate Patient Safety Awareness Week (www.npsf.org/hp/psaw/). We encourage you to invite your patients, visitors, and staff to visit ConsumerMedSafety.org, our new consumer website (www.consumermedsafety.org), and to sign up for free, personalized drug safety alerts.

    ISMP teleconference. Join ISMP and our guest speakers from Brigham and Women’s Hospital and the Cleveland Clinic for our next teleconference, Enhancing Medication
    Safety: The Role of Safe Labeling, Bar Coding, and Outsourcing of IV Products, on
    March 12, 2009. You will learn how product labeling, bar-coding technology, and outsourcing
    IV products can reduce the risk of adverse drug events with IV products. For details, please visit:
    www.ismp.org/educational/teleconferences.asp.

    ISMP Safe Medication Management Fellowship. This yearlong learning opportunity, funded by Cardinal Health Foundation, offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. Fellows have the unique opportunity to make a real difference in medication safety. Fellowship information and application can be found at: www.ismp.org/profdevelopment/managementfellowship.asp. Applications can also be requested by calling 215-947-7797 or via mbell@ismp.org. All applications must be received by March 31, 2009.

    ISMP Medication Safety Intensive. This intensive workshop will help you look at your organization “through the eyes of ISMP” medication safety experts, who will take you though their real-world experiences in establishing and evaluating medication safety programs. Three dates are scheduled in 2009, and space is limited. For more information about the program and to register, please visit: www.ismp.org/educational/MSI.

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