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The following are excerpts from the newsletter

June 12, 2002

  • What's in a name? Ways to prevent dispensing errors linked to name confusion


  • A medication error trifecta!
    newsletter, we described many concerns with insulin therapy. With such complexity, it's not surprising that errors with insulin are frequent and characteristically harmful to patients. As such, this high-alert medication requires special handling.
  • Safety Briefs
    • Do you have a "Suggestion Box" for staff and visitors to quickly share ideas for improvement? This is an easy way to tap into the insightful perspective and creative solutions of patients, visitors, and staff.
    • On June 5, 2002, Sens. Breaux (D-LA), Frist (R-TN), Gregg (R-NH), and Jeffords (I-VT) introduced the Patient Safety and Quality Improvement Act (S. 2590). The bill provides legal protection for medical error information submitted voluntarily to Patient Safety Organizations such as ISMP, USP, FDA, ECRI, etc.
    • Two patients undergoing electro-convulsive therapy (ECT) felt their procedures because of a medication error. Prior to ECT, anesthesia staff intended to give the patients etomidate (a general anesthetic), but instead administered neostigmine (an anesthetic reversal agent).


    • Earlier this year TAP Pharmaceuticals introduced PREVACID (lansoprazole) Packets (15 mg and 30 mg) for preparing oral suspensions for patients who can't swallow capsules. The content of these packets is mixed with 30 mL of water just before ingestion. This product is not for patients who need the medication administered through a feeding tube. Ref: Drug Information Center, University of Illinois at Chicago, College of Pharmacy (www.uic.edu/pharmacy/services/di/ppis.htm ).

June 26, 2002

  • Pharmacy interventions can reduce clinical errors - Part I of findings from ISMP survey
  • Results from Part I of ISMP Survey on Pharmacy Interventions
  • Assure proper mixing of dual-chamber bags
    A serious error occurred in a hospital where dual-chambered IV bags (lower chamber contains amino acids and the upper chamber 50% dextrose) were used to mix parenteral nutrition solutions. Learn what went wrong and strategies to prevent similar errors.
  • Safety Briefs
    • ISMP and the Pediatric Pharmacy Advocacy Group (PPAG) have collaborated to publish the first comprehensive consolidation of recommendations to reduce the risk of medication errors in the pediatric population. The document, Guidelines for preventing medication errors in pediatrics, is endorsed by the Society of Pediatric Nurses.
    • Recently a physician confused VALTREX (valacyclovir) and VALCYTE (valganciclovir). We also received a report about an error involving anakinra (KINERET) where the drug was ordered by telephone and the pharmacy sent amikacin (AMIKIN). In both cases it was the non-proprietary name that led to confusion.
    • The Roman numeral four in "Becton Dickinson Micro-Fine IV needle for insulin may be misinterpreted as "intravenous." Similar errors have happened with other Roman numeral presentations on drug labels.
    • Risk factors for prescribing errors were documented in a study by Dean et al. This article reviews the study. These included work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organizational factors also were identified.

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