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The following are excerpts from the newsletter

June 14, 2000

  • Patient safety movement calls for reexamination of multidose vial use
  • Confusing computer-generated MAR format may be a source of errors
  • 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 order verification.
    • Don't let your guard down. We still receive reports of confusion between CELEBREX, CEREBYX and CELEXA.
    • 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.

June 28, 2000

  • Oral liquid medications may be more vulnerable to errors than previously recognized
  • Isoproterenol additive syringes bear dangerous attributes similar to older lidocaine syringes
  • 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

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