The following are excerpts from the newsletter
- Over-reliance on pharmacy computer
systems may place patients at great risk
- Need a new computer system?
Check out ISMP's top ten signs
- Checking functions require staff's undivided attention
- Safety Briefs
- Goldline Laboratories agrees to change lableling of
unit dose hydralazine and hydroxyzine to help avert
Above is a picture of the original labeling
that may cause the confusion.
- On page 673B of Facts and Comparisons loose leaf edition,
DOXIL (liposomal doxorubicin) is listed with conventional
doxorubicin in a product table. It might be easy for
an inexperienced health professional to wrongly assume
that Doxil is generically equivalent to a conventional
- Recently a cancer patient was admitted to a hospital,
his physician wrote: "May take own supply of EPO." The
order was interperted to mean epoetin alpha However,
the patient was not anemic. A pharmacist thought something
was wrong and interviewed the patient, who confirmed
that he was taking EPO - evening primrose oil - to lower
- A nurse recently asked if we recommend initialing
medication administration records (MARs) before or after
giving a drug. Documentation should take place IMMEDIATELY
AFTER drug administration. Delayed charting could lead
to overdoses when an unsuspecting colleague providing
coverage for the primary nurse administers an undocumented
dose previously given to the patient.
- On January 28th, Parke-Davis sent a "Dear Doctor"
letter to announce that they will revise CEREBYX vial
and carton labels in response to serious and fatal overdoses
that occurred when total vial contents were misinterpreted.
- Since CELEBREX (celcoxib) joined the market last month,
we have received reports of mix-ups with CEREBYX (fosphenytoin).
- "Magic words" or "red flags?"
- Visual cues should provide clues (use unexpected medication
color to detect errors)
- Safety Briefs
- "TPN" is now being used as a chemotherapy acronym.
- CEREBYX, CELEBREX, CELEXA and now there's CEREBRA.
Be alert to these four trademarks which share common
- Be sure to stress the importance of both drug concentration
and volume during initial training and ongoing education
so that technicians who prepare solutions can play an
important role in detecting prescribing and/or order
- Yes, it can (and did) happen again! Another mixup
between mg and mL of aminophylline
- The CEREBYX monograph found in Intravenous Medications,
by Gahart and Nazareno (St. Louis. Mosby 1999) needs
to be corrected immediately wherever the book may be
in use within your institution.