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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

january 17, 2008

  • ADC survey shows some improvements, but unnecessary risks still exist
  • Don’t use epidural tubing for an IV solution
  • Topical antiseptic given orally.
  • 4% chlorhexidine gluconate solution intended for use as a topical surgical skin prep was administered as an oral rinse. Read this brief to learn about events that contributed to the error and measures your organization can take to prevent a similar occurrence.

  • Refrigerator monitoring.
  • Provisions for storing medications and vaccines according to manufacturer’s directions must be in place to assure therapy will be delivered as intended. Faulty refrigeration practices are linked to numerous problems detailed in this SafetyBrief.

  • AHRQ compares choices.
  • Effective Health Care is a federally sponsored program that assists consumers in identifying the most effective treatment for significant health conditions. This article explains the program and tells organizations how to access this valuable patient education resource.

Special Announcements…
  • ISMP teleconferences.

    Please join us for our first 2008 teleconference, Safe Use of ADCs: Choosing Safety Over Convenience, to be held on January 30 from 1:30-3:00 p.m. ET. Speakers will address common errors associated with the use of automated dispensing cabinets (ADCs) and present new consensus recommendations designed to improve formulary management, drawer configuration, restocking procedures, system overrides, and medication withdrawal and transport. To register, visit: www.ismp.org/educational/teleconferences.asp.
    Mark your calendars for a series of teleconferences that will address how to reduce the risk of patient harm with high alert drugs.  The series includes: Reducing the Risk of Patient harm with Anticoagulation Therapy on February 21, 2008; Reducing the Risk of Harm with Opiates on March 26, 2008; and Preventing Errors with Insulin: A Multidisciplinary Approach on April 23, 2008.  To register for any of these conferences, visitwww.ismp.org/educational/teleconferences.asp.
    Safe Medication Management Fellowship.

  • ISMP is now accepting applications for the Safe Medication Management Fellowship, sponsored by Cardinal Health Foundation. A teleconference about the program will be held on February 18, 2008 for those interested in learning about this unique opportunity. Send an e-mail to info@ismp.org to receive more information and a pass code to attend the teleconference.

january 31, 2008

  • Fatal overdose uncovers need to rethink where pediatric IV medications are dispensed and administered
  • Solving label problems.
  • Manufacturers may print numbers and dates on product packaging that provides confusing or conflicting data to healthcare providers. Read about error-prone labeling on two Roxane products and how the company plans to resolve the problems.

  • Camphor and childhood seizures.
  • The New York City Department of Health recently reported several instances in which accidental exposure or unapproved use of concentrated camphor products led to seizures in children. This SafetyBrief describes why camphor products may be found in home settings and what healthcare providers can do to curtail off-label use.

  • MEDMARX report issued.
  • The United States Pharmacopeia issued its 8th annual report which focused on how drug nomenclature contributes to medication errors. Nomenclature-driven sources of error as well as recommended solutions are discussed in the full report.

Special Announcements…
  • ISMP teleconferences.
    Please join us for the first of three teleconferences on high-alert medications, Reducing the Risk of Patient Harm with Anticoagulant Therapy to be held on February 21 from 1:30-3:00 p.m. ET. ISMP medication safety experts will guide you through the steps needed to implement a hospital anticoagulation management program. To register, visit: www.ismp.org/educational/teleconferences.asp.
  • Mark your calendars for other teleconferences in a series designed to help organizations reduce the risk of patient harm with high alert drugs.  Upcoming teleconference include “Reducing the Risk of Harm with Opiates” on March 26, 2008 and “Preventing Errors with Insulin: A Multidisciplinary Approach” on April 23, 2008.  To register for any of these conferences, visit www.ismp.org/educational/teleconferences.asp.
  • Safe Medication Management Fellowship.

    ISMP is now accepting applications for the Safe Medication Management Fellowship, sponsored by Cardinal Health Foundation. A teleconference about the program will be held on February 18, 2008 for those interested in learning about this unique opportunity. Send an e-mail to info@ismp.org to receive more information and a pass code to attend the teleconference.

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