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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

february 10, 2011

  • Preventing medication errors during codes
  • Safety Brief: Adjust PRADAXA dose
    We hope healthcare practitioners are paying as much attention to safe prescribing of the oral direct thrombin inhibitor PRADAXA (dabigatran etexilate mesylate) as they would warfarin. In a recent report, Pradaxa was prescribed by a cardiologist for a patient who later presented with weakness, black tarry stools, and was also found to have a low hemoglobin and hematocrit. Check out this week’s newsletter to learn more about the events that led to the patient’s deterioration, along with dose adjustment recommendations for dabigatran.
  • Safety Brief: Important recall
    We don’t typically publish recalls, but we occasionally make exceptions for very serious issues. Learn more details about this important recall.
  • Safety Brief: Federal legislation to address drug shortages
    New legislation was introduced in the US Senate on February 7, 2011 to support FDA efforts to address drug shortages. The legislation was supported by several professional organizations. You can learn more about the legislation and the endorsing organizations by reading this week’s issue.
  • Safety Brief: Nicotine—nitroglycerin patch mix-up
    A pharmacist told us about two incidents in which nicotine transdermal patches were dispensed to patients instead of nitroglycerin patches. Find out more.
Special Announcements
  • New ISMP staff
    We are pleased to announce that Christina Michalek, RPh, BS, FASHP, has joined ISMP as a Medication Safety Specialist and member of the ISMP consulting team. Chris has served as a consultant and advisor to ISMP since 2001. She has over 20 years of hospital pharmacy practice experience, the majority of which was spent in leadership roles, including director of pharmacy at the Lehigh Valley Health Network, Muhlenberg Campus, and Doylestown Hospital, both in PA. Chris has extensive experience in implementing health-system technologies including robotic dispensing and bedside bar-coding. She is also a past ISMP CHEERS Volunteer Award (2009) recipient.
  • Unique 2-day program
    Attend ISMP’s Medication Safety INTENSIVE workshop, a live, one-of-a-kind, interactive program with ISMP staff that will teach you how to approach medication safety “through the eyes of ISMP.” The workshop will be held in two locations during 2011. For details, visit: www.ismp.org/educational/MSI.
  • ISMP webinars
    On March 3, ISMP will present a multifaceted webinar on Safe Injection Practices: A Call to Action. A recent online survey revealed an alarming lapse in basic infection control practices—including several widespread misconceptions— associated with the use of    needles, syringes, and multiple- and single-dose vials. Webinar participants will hear from representatives of the Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), The Joint Commission, and the Premier Institute’s lead author of the published online survey on injection practices as they lead a discussion on safe injection practices and present information about their organizations’ efforts to improve injection safety. For details on both webinars, visit: www.ismp.org/educational/webinars.asp.
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

february 24, 2011

  • That's the way we do things around here!
    Your ACTIONS speak louder than words when it comes to patient safety
  • Capsules that have short expiration date after bottle opened
    We received two reports regarding unit-of-use bottles of a new medication with an unusually short drug expiration date once opened. The bottles do not come with a tamper-evident seal, so patients who have more than one bottle on hand may not be able to easily tell which one has been previously opened. Check out this week’s issue to find out more.
  • WorthRepeating: Anticoagulant-Plasma volume expander mix-ups
     Since October 2010, we have received four reports of mix-ups between anticoagulant and plasma volume expander products. One case occurred in the operating room (OR); where the anticoagulant was nearly administered in error to treat hypotension. Find out more about these mix-ups and how to prevent them.
  • Safety Brief: Caution if using outsourced electrolyte concentrate minibags
    With a shortage of concentrated vials of a particular electrolyte in the marketplace, a minibag of the electrolyte solution has become available from an outsource IV compounding company (other companies may also provide this product). We continue to be concerned about concentrated electrolytes being supplied in a minibag instead of a vial. Find out which measures need to be in place prior to introducing such products to your organization.
  • Safety Brief: Implantable pumps recall
    An FDA requested recall, has been issued by Medtronic for 2 series of implantable pumps. The company noted that 8 deaths and 270 serious injuries have been reported worldwide after drugs or fluids intended to refill the pump’s reservoir were inadvertently injected into the subcutaneous tissue pocket surrounding the implanted pump. Learn more in our newsletter.
  • Library additions
    Two useful additions to the ISMP library have arrived. The new books include Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, edited by ISMP advisors John W. Gosbee and Laura Lin Gosbee (published by Joint Commission Resources) and Knowing Your Medications: A Guide to Becoming an Informed Patient, written by ISMP QuarterWatch co-author Curt D. Furberg and his colleagues Bengt D. Furberg and Larry D. Sasich. The first book presents an overview of human factors engineering principles, methods, and tools, including chapters on human factors topics related to patient safety and a chapter on integrating human factors engineering into medication safety at ISMP Canada. The second book is written in a Question and Answer format. This book would be excellent for patients to help them evaluate the safety and effectiveness of prescription medications while also providing a unique perspective on medications for healthcare providers, students, policy makers, and journalists. Both books are available at online bookstores.
Special Announcements
  • ISMP webinars On March 3, ISMP will present a webinar on Safe Injection Practices: A Call to Action. A recent online survey revealed an alarming lapse in basic infection control practices associated with the use of needles, syringes, and multiple- and single-dose vials. Participants will hear from the FDA, CDC, The Joint Commission, and the Premier Institute’s lead author of the published survey on injection practices as they lead a discussion on safe injection practices. For details, visit: www.ismp.org/educational/webinars.asp.
  • ISMP Fellowships funded
    We are pleased to announce two ISMP Safe Medication Management Fellowships along with our shared fellowship with FDA. The CareFusion Foundation is sponsoring the Stephen R Lewis, MD Fellowship at ISMP in memory of their former Chief Medical Officer and senior vice president of the Center for Safety and Clinical Excellence. In addition, the Medco Foundation is sponsoring a fellowship. Our third fellowship, the ISMP-FDA Fellowship, is available for individuals who will spend six months at ISMP and six months at FDA. We greatly appreciate the support of the CareFusion and Medco Foundations and FDA for their investment in these important medication safety training programs. For more information about the fellowships see the announcement on the last page of this week’s newsletter.
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication.

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