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THE FOLLOWING ARE EXCERPTS FROM THE NEWSLETTER

january 13, 2011

  • Guidelines for timely medication administration
    Response to the CMS "30-minute rule"
  • Safety Brief: Standard NICU drug infusion concentrations
    Few would disagree that standardizing the concentrations of drug infusions has enormous potential for increasing safety, especially in neonatal care. An effort to standardize neonatal drug infusion concentrations nationally is well underway through a joint effort of ISMP and the Vermont Oxford Network (VON), a non-profit voluntary collaboration of healthcare professionals dedicated to improving the quality and safety of medical care for newborn infants. Check out this week’s newsletter to find out more about this collaborative and access the established standard concentrations.
  • Safety Brief: Limits placed on prescription transfers by patients
    One State Board of Pharmacy is now limiting the number of times a specific prescription may be transferred between community pharmacies. Pharmacists in that state had complained about the time spent dealing with prescription transfers initiated solely because of cash or other incentives offered by competitor pharmacies. You can learn more about the hazards of transferring prescriptions across pharmacies, as well as which Board of Pharmacy implemented these new limits by reading our newsletter.
  • Safety Brief: Top drugs that cause violence
    The link between violence and prescription drugs is the subject of a study, led by Thomas Moore, ISMP consulting scientist. Find out which drugs were involved in the study in our current issue.
Special Announcements
  • ISMP webinars February: Join us for our first webinar of 2011, Improving Medication Safety Through Effective Error Reporting, which will be held on February 9. The value of reporting medication errors in healthcare organizations is often limited by cumbersome, time-consuming reporting methods and ineffective use of the information. This webinar will cover the types of medication error and hazard data worth gathering, analysis of that data, and the importance of providing feedback to frontline staff about risks, errors, and error-prevention strategies.
  • March: On March 3, 2011, 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 Fellowship ISMP is now accepting applications for its 2011-2012 Safe Medication Management Fellowship. This 1-year learning opportunity offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. The application deadline for the 2011-2012 fellowship is March 31; for more information and a copy of the application, visit: www.ismp.org/profdevelopment/managementfellowship.asp.
  • 1-week rotation at ISMP We have room for one more participant in our week-long ISMP Practitioner in Residence Program, which will be held February 14-18, 2011, at ISMP’s office in suburban Philadelphia, PA. The Program provides healthcare professionals who have medication safety oversight in their organization with a unique opportunity to work closely with ISMP experts on individual projects, explore and discuss intensive learning modules on high-priority topics, and practice using ISMP’s proven model for identifying and controlling risks associated with medication use. For details, visit: www.ismp.org/consult/.
      
    Linking the lab and pharmacy The AHRQ Center for Education and Research on Therapeutics at the University of Illinois at Chicago College of Pharmacy has been presenting a webinar series on preventing medical errors by improving the linkage between the lab and pharmacy. The last webinar will be held on January 20, 2011. For details, visit: http://projectpatientcare.org/events/overview

  • 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.

january 27, 2011

  • ISMP QuarterWatchT Report (2010 Quarter 2) Adverse drug event signals warrant action
  • Safety Brief: Error prevention during another Tamiflu suspension shortage
    Similar to what happened last year during the flu season, Genentech announced last week that TAMIFLU (oseltamivir phosphate) Oral Suspension is on backorder again due to high demand. When this occurred last year, dosing errors were reported to us because the FDA-approved procedure in the product labeling for preparing the pharmacy-compounded oral suspension from capsule powder. Check out this week’s newsletter to find out more.
  • Safety Brief: Health professionals or policemen?
    From time to time, we hear from hospitals that continue to be cited by The Joint Commission for not properly addressing the use of abbreviations in medical orders that appear on the organization’s “Do Not Use” list. As a solution, several hospitals or medical staff leaders unload the problem on pharmacists and/or nurses, requiring them to contact prescribers to address this issue, which leads to strained relationships among them. Learn how hospitals experiencing a similar problem can address this with their staff.
  • Safety Brief: Error with nonformulary drug
    On the first day of a patient’s hospital admission, medication reconciliation was completed and the patient’s attending physician wrote orders for all the patient’s home medications. Nephrology was consulted since the patient had chronic renal disease. At home, the patient had been taking a medicaction for an overactive bladder. In the hospital, that medication was a nonformulary drug and not in the computer system. The central order-entry pharmacist received the order, misread it, and profiled an immunosuppressant on the hospital formulary. You can find out more about which medications were involved in this error by checking out this week’s newsletter.

Special Announcements

  • ISMP webinars
    February: Join us for our first webinar of 2011, Improving Medication Safety Through Effective Error Reporting, which will be held on February 9. The value of reporting medication errors in healthcare organizations is often limited by cumbersome, time-consuming reporting methods and ineffective use of the information. This webinar will cover the types of medication error and hazard data worth gathering, analysis of that data, and the importance of providing feedback to frontline staff about risks, errors, and error-prevention strategies. 
  • March: 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.
  • Fellowships
    ISMP Fellowship:  ISMP is now accepting applications for its 2011-2012 Safe Medication Management Fellowship. This 1-year learning opportunity offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. The application deadline is March 31.
  • FDA/ISMP Fellowship:  FDA and ISMP are now accepting applications for their joint 2011-2012 FDA/ISMP Safe Medication Management Fellowship. This year-long program provides experienced candidates an unparalleled opportunity to learn from and work with the medication safety staff at ISMP and FDA. The application deadline is March 31. For details on both Fellowships, visit: www.ismp.org/profdevelopment/.
  • 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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