The following are excerpts from the newsletter
- Patient safety movement calls
for reexamination of multidose vial use
- Confusing computer-generated MAR format may be a source
- Safety Briefs
- Pharmacia prompted to make changes to Detrol unit dose
packaging to help reduce errors.
Current Detrol unit dose packaging
- CPOE does not diminish the important role that pharmacists
must play in patient safety through concurrent DUR and
- Don't let your guard down. We still receive reports
of confusion between CELEBREX, CEREBYX and
- Name confusion with older sufonylureas and other types
of antidiabetic agents leads to errors.
- Thanks for your patience while awaiting delivery of
the ISMP Medication Safety Self Assessment! If
you are a pharmacy director and have not received your
hospital's copy yet, please check with your "mail room"
to assure that it is not awaiting distribution with other
bulk mail. Otherwise, contact us at 215 947 7797 for a
copy. We are excited about the high level of participation
already evidenced by those who have submitted their findings
to ISMP! Remember, you cannot submit your findings to
ISMP without your assigned password, which is located
on the last page of the original copy of the assessment.
- Caution! A new dietary product, CHOICE DM, does
not contain dextromethorphan. Instead, the suffix signifies
the product's usefulness as a carbohydrate source in patients
with diabetes mellitus.
- Oral liquid medications
may be more vulnerable to errors than previously recognized
additive syringes bear dangerous attributes similar to older
- June is national safety month
- Safety Briefs
- FDA is considering label changes for CEREBYX (fosphenytoin)
to reflect cardiovascular events seen post-marketing.
- Two new U.S. Senate bills reject a national mandatory
error reporting effort, which was recommended in the November
30, 1999, Institute of Medicine report, "To Err is Human."
On June 15, U.S. Senators Jim Jeffords (R - VT) and Bill
Frist (R - TN) introduced the "Patient Safety and Errors
Reduction Act of 2000." On the same day, Senators Ted
Kennedy (D - MA) and Christopher Dodd (D - CT) introduced
the "Error Reduction and Improvement in Patient Safety
Act of 2000."
- Congratulations to Dr. Neil M. Davis, co-founder of
ISMP, on receiving health-system pharmacy's highest honor,
the H.A.K. Whitney Award, at the American Society of Health-System
Pharmacists meeting this month in Philadelphi