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July 12, 2007
- Joint Commission Update
It’s not too late to register for our teleconference, Joint Commission Update: 2007-2008 Requirements Related to Medication Use, to be held on July 18, and repeated on August 2. Please visit www.ismp.org/educational/teleconferences.aspfor details about the 2008 safety goals and standards that will be discussed.
- Employment opportunity.
ISMP is seeking a full-time RN with clinical and managerial experience to support its consulting group. For details, visit: www.ismp.org/jobline/joblist.asp?jobType=I.
July 26, 2007
- Failure to cap IV tubing and disinfect IV ports place patients at risk for infections
- Numerous problematic name pairs relegated to history.
Reliant Pharmaceuticals is poised to announce that OMACOR, used in the treatment of hypertriglyceridemia, will soon undergo a name change to LOVAZA. This action is being undertaken to reduce mix-ups between Omicor and AMICAR, an antifibrinolytic agent. Read on to learn more about problematic name pairs that resolved following name changes.
- Insulin CONCENTRATE U-500.
ISMP continues to receive reports of errors involving orders for regular insulin U-500 instead of U-100. In light of rising use of U-500 insulin products in acute care settings, measures to prevent prescribing and dispensing errors should be undertaken.
- WHO: Dilute vincristine in a minibag.
Last week the World Health Organization published a drug alert about vincristine following the death of a 21-year-old woman in Hong Kong. WHO called for dilution of the drug in a minibag and said not to dispense it in a syringe, recommendations consistent with those made by ISMP.
World Health Organization: Information Exchange System - Alert No. 115, Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag
- Using PDAs to reduce errors.
A study of nursing students who used personal digital assistants (PDAs) showed that PDAs have the potential to reduce medication errors and improve efficiency.
- Hydromorphone survey.
FDA is working with ISMP to reduce the risk of drug-name mix-ups between morphine and hydromorphone, including the possibility of establishing a consistent way to present hydromorphone using tall man letters. Take our quick survey at: www.ismp.org/survey/tallman.asp by August 10, 2007.
- ISMP teleconference.
Please join us for our next teleconference, Reducing the Risk of Patient Harm with Anticoagulant Therapy, to be held on September 19, 2007, from 1:30 to 3:00 p.m. ET. With a special focus on heparin and warfarin, this teleconference will provide you with the building blocks necessary to define and implement an anticoagulant management program, as required by a 2008 Joint Commission National Patient Safety Goal. Visit www.ismp.org/educational/teleconferences.asp for details.