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The following are excerpts from the newslette

  • Messages in our mailbox
  • Don't overlook pre-analytical variables when assessing lab results
  • Safety Briefs
    • Your "lessons learned" reach over 2.5 million. Based on 698 responses to our recent subscriber survey, we've been able to estimate that about 560,000 US practitioners receive the ISMP Medication Safety Alert! But the good news does not stop there! We also have regular medication error prevention columns in over 16 professional journals and healthcare newsletters that reach a large (2 million) and varied audience, from health care executives to the pharmaceutical industry.
    • Although not labeled for intrathecal use, intrathecal midazolam HCl has a small but increasing use in pain control. However, preservatives used in commercial dosage forms of midazolam HCl injection have been a barrier to such use
    • Nurses typically verify placement of enteral tubes before administering feedings or medications to prevent inadvertent delivery into the lungs. A recent report described a new way of assessing whether an enteral tube is intragastric or intrapulmonary for patients in the intensive care unit
    • The Food and Drug Administration (FDA) has announced the creation of a new Drug Safety and Risk Management Subcommittee to the Advisory Committee for Pharmaceutical Science. These experts will advise FDA on general and product-specific safety issues. ISMP's Michael Cohen will serve as a member of the subcommittee, which is expected to have its first public meeting in the spring.
    • Your input is needed on issues related to bar coding and unit dose packaging of pharmaceutical products! If you haven't done so yet, please complete the survey on these issues that was included in our December 12, 2001 newsletter. You also can find the survey on our website. The deadline for responses is January 18.
    • The National Patient Safety Foundation (NPSF) is calling for Letters of Intent for research proposals that enhance patient safety. Any official member of a not-for-profit institution in the US may apply. The awards will be up to $100,000 for projects up to 2 years in duration. Submission deadline is March 15, 2002. NPSF's objective is to promote studies leading to prevention of human errors, system errors and any form of preventable injuries in healthcare and the adverse consequences to patients that may result.
    • ISMP holding live teleconference on FMEA
      ISMP will be conducting a special 1 ½ hour teleconference on failure mode and effects analysis (FMEA) on February 20, 2002, at 2 p.m. EST. FMEA is now required as part of the Joint Commission on Accreditation of Healthcare Organization's (JC) Patient Safety Standards. Learn simplified methods for examining new products, services and processes to determine points of potential failure and what their effect would be - before any error actually happens. ISMP's Michael Cohen will moderate the program. Darryl Rich of the Joint Commission will review the JC requirement. Susan Proulx of ISMP's Med- E.R.R.S. division will describe how the process is used to evaluate error potential of new product labels, packages, and names. Mary Burkhardt of the Veterans Health Administration Center for Patient Safety will review the FMEA method used by the VA. Cost is $175 per phone connection (several may participate using a speakerphone).

January 23, 2002

  • Shortsighted JC standard lacks understanding of pharmacist's role in prospective order review
  • ISMP Quarterly Action Agenda: October - December 2001
  • Safety Briefs
    • Once again, a well-known problem has led to a fatality. TIMENTIN (ticarcillin and clavulanate potassium) 3.1 grams IV was ordered for a patient after the pharmacy had closed. A nursing supervisor went into pharmacy, but could only find the pharmacy bulk package which contains 31 grams. A staff nurse assumed that each vial contained one dose. She gave the patient one vial at 1 am and another at 5 am. For recommendations on safe medication access when a pharmacist is unavailable, please see our May 30, 2001 newsletter issue.
    • When changes occur, it's easy to overlook less obvious areas that may be affected. We received two error reports that demonstrate this well. First, a hospital received a new batch of thromboplastin that changed the range of a therapeutic aPTT from 45-60 seconds to 40-70 seconds. A preprinted IV heparin nomogram was used for dose adjustments based on the aPTT values. For a short time, the preexisting nomogram was used with the new batch of thromboplastin, leading to unnecessary dose adjustments and repeat testing. In the second case, a hospital temporarily changed from morphine 15 mg/mL to a 50 mg/mL concentration to make infusions and PCA syringes. Compounding instructions in the pharmacy computer had been altered to reflect this change. But staff forgot that a specific standing order, which included a morphine drip and compounding instructions using the 15 mg/mL concentration, had been entered into the pharmacy computer.
    • In recognition of the drug's well-known teratogenicity, THALOMID (thalidomide) capsules are approved for marketing only under a special restricted drug distribution program called STEPS (System for Thalidomide Education and Prescribing Safety). To ensure compliance, FDA requires that patients receive their doses in a special blister pack with label warnings to prohibit repackaging of the medication and ensure that the teratogenic alerts and use instructions remain with the drug. The blister pack is not perforated to separate each capsule, so the nurse is expected to push each dose through the foil and leave the package otherwise intact and properly labeled. One pharmacist recently discovered a blister pack that had been cut apart into individual doses, leaving most of the capsules unlabeled.
    • ISMP announces the availability of three, full-time, post-graduate training programs beginning this summer at our offices in Huntingdon Valley, PA (near Philadelphia). The ISMP Safe Medication Management Fellowship trains a health professional with at least one year of clinical experience. The Scholar-In-Residence Program, funded by a grant from the Merck Foundation, trains a pharmacist with at least three years of practice experience. The Managed Care Fellowship Program, funded through a grant from Independence Blue Cross of Philadelphia, is a shared position with Temple University, Independence Blue Cross, and ISMP to train a health professional interested in patient safety issues in managed health care. Call 215-947-7797 or contact us via email to request a syllabus and application form for these programs.
    • ISMP will be conducting a special 1 ½ hour teleconference on failure mode and effects analysis (FMEA) on February 20, 2002, at 2 p.m. EST. FMEA is now required as part of the Joint Commission on Accreditation of Healthcare Organization's (JC) Patient Safety Standards. Learn simplified methods for examining new products, services and processes to determine points of potential failure and what their effect would be - before any error actually happens. ISMP's Michael Cohen will moderate the program. Darryl Rich of the Joint Commission will review the JC requirement. Susan Proulx of ISMP's Med-E.R.R.S. division will describe how the process is used to evaluate error potential of new product labels, packages, and names. Mary Burkhardt of the Veterans Health Administration Center for Patient Safety will review the FMEA method used by the VA. Cost is $175 per phone connection (several may participate using a speakerphone).

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