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The following are excerpts from the newsletter

January 11, 2007

  • High alert drug focus in 2007
  • SSRI or SSKI?

    Be aware that "SSKI" (potassium iodide) can also be confused with "SSRI."

  • Seasonal mix-ups
  • Mix-ups between ZYRTEC (cetirizine) and ZYPREXA (olanzapine) seem to spike in the winter months. No doubt this is related to an increase in prescribing Zyrtec for influenza and cold symptoms.

  • Tragedy brings a measure of good

  • The Wisconsin nurse who was facing criminal charges in the tragic medication error-related death of a young mother entered a no contest plea in court to two misdemeanor counts of illegally administering prescription medications. The nurse is required to take classes on preventing medication errors and to make presentations about what she learns to help others avoid medication errors. To help facilitate this, the Texas Medical Institute of Technology has offered her a yearlong fellowship.

Special Announcements

  • Education
  • Please join us for our next teleconference, Gaining Physician Compliance to Your Patient Safety Initiatives, to be held on February 22, 2007, from 1:30-3:00 p.m. EST. ISMP Medical Director and trustee Russell Jenkins, MD, will explore how to win, not just enforce, physician compliance to organizational safety goals. Visit www.ismp.org/educational/teleconferences.asp to register.

  • Support

  • Registration for Series I of the ISMP Rural Hospital Medication Safety Connection is full, but we are still accepting registrations for Series II (a repeat of Series I), which begins on February 6. This collaborative, uniquely tailored to rural hospitals, offers a comprehensive tool set, live interaction with ISMP experts via audio-conferences, and more! Visit www.ismp.org/Consult/ruralhospital/default.asp to register.

January 25, 2007

  • The five rights: a destination without a road map
  • Ambulatory care e-Rx errors

    While electronic prescribing (e-Rx) in the ambulatory care environment undoubtedly improves medication safety, flawed prescriptions risk misinterpretation. Errors have occurred when prescribers inadvertently choose the wrong item from a drug selection data base.

  • No cough and cold meds for little ones, please
  • In the January 12, 2007 Morbidity and Mortality Weekly Report (MMWR), a report was published about infant deaths associated with cough and cold medications. All infants were found to have high levels of pseudoephedrine in postmortem blood samples.

  • Don’t abbreviate drug names

    We recently received a report where mycophenolate mofetil (CELLCEPT) was prescribed using the abbreviation, “MMF 1000 mg po BID”. Unfortunately, an error ensued. Guess what happened?
  • ISMP Quarterly Action Agenda

    The October – December 2006 ISMP Quarterly Action Agenda appears in the PDF version of the newsletter. Subscribers can also download a Word version of the Action Agenda (www.ismp.org/Newsletters/acutecare/actionagenda0701.doc), which allows expansion of the boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Special Announcements

  • Education
  • Please join us for our next teleconference, Gaining Physician Compliance to Your Patient Safety Initiatives, to be held on February 22, 2007, from 1:30-3:00 p.m. EST. ISMP Medical Director and trustee Russell Jenkins, MD, will explore how to win, not just enforce, physician compliance to organizational safety goals. Visit www.ismp.org/educational/teleconferences.asp to register.

    HIMSS Conference. The Annual Healthcare Information and Management Systems Society (HIMSS) Conference and Exhibition will be held in New Orleans from February 25- March 1, 2007. The conference, which includes symposia in pharmacy, physician, and nursing informatics, will give you the opportunity to learn the latest industry intelligence. For information, visit: www.himss.org/ASP/index.asp.

    FDA-ISMP-USP meeting. On January 11, 2007, FDA’s Center for Drug Evaluation and Research (CDER), ISMP, and USP held a joint public meeting on improving patient safety through enhancing the container labeling for parenteral infusion drug products. The purpose of the meeting was to explore how labels on intravenous (IV) drug products could be designed to minimize medication errors. Time was also allotted for public comment during the meeting. A copy of all presentations is available at https://www.fda.gov/cder/meeting/parenteral/presentations.htm. A meeting transcript will be available shortly.
  • Support

  • Registration for Series I of the ISMP Rural Hospital Medication Safety Connection is full, but we are still accepting registrations for Series II (a repeat of Series I), which begins on February 6. This collaborative, uniquely tailored to rural hospitals, offers a comprehensive tool set, live interaction with ISMP experts via audio-conferences, and more! Visit www.ismp.org/Consult/ruralhospital/default.asp to register.

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