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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

february 11, 2010

  • FDA Advise-ERR: A new look for Morphine Sulfate 100 mg per 5 mL (20 mg/mL) Oral Solution
  • Is it time to eliminate reverse numbering systems for narcotic counts?

    ISMP has received several error reports involving administration of the wrong dose of an oral opioid due to reverse numbering systems on oral opioid unit dose blister packages. Learn how reverse numbering systems contributed to these errors and what some drug manufacturers are doing to remedy the problem.  

  • Safety Brief: Drug name mix-up.

    Two patients received levetiracetam (KEPPRA) instead of levocarnitine (CARNITOR).  Find out what strategies your organization can implement in order reduce the risk of mix-up between these two medications.

  • Safety Brief: Wrong insulin concentration.

    A patient received an insulin infusion that was five times the intended dose. Read more about this event, including the contributing factors that lead to the error, and ISMP’s recommendations for how other healthcare facilities can minimize the risk of a similar error within their own organization.

  • Safety Brief: Ambiguous bisacodyl directions.

    A patient misunderstood the directions for use on an over-the-counter bisacodyl product.  Learn which bisacodyl product the patient had purchased and how the directions for this and/or other bisacodyl products in your pharmacy may also contribute to confusion.

Special Announcements
  • March 7-13: Patient Safety Awareness Week.

    If you are planning events for patients, community groups, or area businesses, consider showing Patients Play a Vital Role in Patient Safety, a video distributed by ISMP. The program is just 20 minutes long, but it covers realistic scenarios of risks, and practical, expert advice to help patients become active participants in their own care and safety. Hospitals are also encouraged to show this video on their patient education channel; suggested viewing locations include preadmission testing and outpatient waiting areas. To order a copy, visit:
    http://onlinestore.ismp.org/shop/item.aspx?itemid=146.

  • ISMP webinars. 

    • February 18, 2010: Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets (ADCs). Preliminary data since the launch of the self assessment will be presented along with recommendations to further improve the safe use of ADCs. For details and to register, please visit: http://www.ismp.org/educational/webinars.asp.
    • March 23, 2010: Measuring up to medication safety: Where do you stand?Measuring the level of safety is fundamental to improvement. Yet, measuring medication safety has long been a challenge. Learn about the methods you can use to effectively measure medication safety in your organization and determine whether your improvement efforts are successful. For details and to register, please visit: www.ismp.org/educational/webinars.asp.

february 25, 2010

  • ISMP QuarterWatchT (2009 Quarters 1, 2, and 3)
    Increased reports of ADEs with Zicam cold products, rosiglitazone, QUEtiapine, testosterone gel, and recalled products
  • Maalox Total Relief isn’t the same great Maalox

    FDA recently alerted the public to the potential for serious side effects if consumers mistakenly use MAALOX TOTAL RELIEF, which contains bismuth subsalicylate, instead of using other Maalox products that contain magnesium and aluminum hydroxides.  Learn what actions the manufacturer, Novartis, has taken in order to reduce the risk for confusion.

  • Eric Cropp released from prison, ISMP meets with Ohio pharmacy board

    ISMP is pleased to report that Eric Cropp, the Ohio pharmacist who was sentenced to a 6-month prison sentence for failing to detect a pharmacy technician’s chemotherapy mixing error, was released from prison on February 12.  Recently, the president and a vice president of ISMP also met with the executive director and assistant executive director of the Ohio State Board of Pharmacy to discuss the decision to revoke Eric’s license.  Check out this issue of the newsletter for further details regarding this meeting.

  • Safety Brief: Multiple concerns regarding oral syringes.

    We have received several concerns from practitioners about certain Baxa oral syringes that may make it difficult to measure an accurate dose with some of these products.  Read more about the specific syringes involved in order to determine if this could be an issue at your facility and what Baxa is doing to address the problem.

  • Safety Brief: “Invanz” or “IV Vanc”?

    After misreading a handwritten recommendation in the progress notes for “Invanz 1 g q 24h” a physician subsequently prescribed vancomycin 1 gram every 24 hours.  Learn how these two drugs can be confused and helpful strategies to reduce the risk of mix-up.

Special Announcements
  • March 7-13: Patient Safety Awareness Week.

    If you are planning events for patients, community groups, or area businesses, consider showing Patients Play a Vital Role in Patient Safety, a video distributed by ISMP. The program is just 20 minutes long, but it covers realistic scenarios of risks, and practical, expert advice to help patients become active participants in their own care and safety. Hospitals are also encouraged to show this video on their patient education channel; suggested viewing locations include preadmission testing and outpatient waiting areas. To order a copy, visit: http://onlinestore.ismp.org/shop/item.aspx?itemid=146.

  • ISMP webinar. 

    Measuring the level of safety is fundamental to improvement. Yet, measuring medication safety has long been a challenge. Join ISMP for our March 23 webinar on Measuring up to medication safety: Where do you stand? to learn about the methods you can use to effectively measure medication safety in your organization and determine whether your improvement efforts are successful. For details and to register, visit: www.ismp.org/educational/webinars.asp.

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