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THE FOLLOWING ARE EXCERPTS FROM OUR NEWSLETTER

June 2, 2011

  • Safe practices in pharmacy sterile compounding areas
  • Safety Brief: Outsourcing pharmacy ships to wrong hospital
    In a hospital that outsources cardioplegia solutions to an IV compounding pharmacy, a pharmacy technician processed a new shipment and found that the name of the hospital on cardioplegia bag labels did not match theirs. Find out more.
  • Safety Brief: Safer syringe labeling
    We have previously expressed concern regarding the use of outsourced color-coded syringes of anesthesia drugs from companies such as PharMEDium, Ameridose, CAPS, and others. Recently, PharMEDium made labeling changes to help allay our initial concerns by improving differentiation of the individual drugs within each class. You can view these changes in this week’s newsletter.
  • ISMP Medication Safety Self Assessment for Hospitals
    Without a doubt, we consider the series of ISMP Medication Safety Self Assessments to be among the most important activities we’ve undertaken since the 1999 Institute of Medicine report, To Err is Human. These projects have helped to identify distinguishing characteristics of a safe hospital medication-use system, and allowed us to nationally monitor hospital efforts to enhance medication safety over time. They have also provided hospital leaders with a comprehensive way to identify opportunities for improvement and compare their hospital’s experience with that of demographically similar organizations. Please help ISMP and our partner organizations, the American Hospital Association (AHA) and the Health Research and Educational Trust (HRET), carry out our 2011 project by assuring that your hospital participates in this critically important effort. For more information, access the project website (www.ismp.org/selfassessments/Hospital/2011/Default.asp), send queries via email to ISMP (selfassess@ismp.org), or call us (215-947-7797).
  • National survey on USP <797> compliance
    We would like to remind pharmacies to participate in the USP <797> compliance study being conducted by Eric Kastango, RPh, MBA, FASHP, and Kate Douglass, MS, RN, APN,C, CRNI. The survey will take about 60-90 minutes (in multiple sittings if desired) and is endorsed by ISMP and other organizations. Please register for the study today at: www.797study.com, using Survey Code A797C.
  • AHA survey on drug shortages
    Hospital CEOs will be receiving a survey from the American Hospital Association (AHA) to assess the impact that drug shortages have on patient safety and quality of care, the financial implications to hospitals and health systems, and the steps being taken in hospitals to cope with these shortages. It’s likely that doctors, pharmacists, and nurses will be contacted by leadership to help complete the survey. AHA is now working with other groups, including ISMP and ASHP, to advocate for changes that could help to ameliorate drug shortages. Data from the survey will be shared only in the aggregate with the media and policy-makers unless otherwise specifically authorized.

Special Announcements

  • ISMP webinars
    • June. On June 29, ISMP will present a webinar on The Pharmacist Perspective: The Expected and Unexpected Results of Computerized Prescriber Order Entry (CPOE) Implementation. Follow the journey of one hospital as it navigates through transformed relationships and altered workflow and efficiency associated with CPOE implementation. Speakers will highlight the challenges to anticipate after the CPOE “go live” date and will share ideas on how to maximize medication safety benefits through the use of CPOE.
    • July. On July 26, ISMP will present a webinar on Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. In traditional patient care units, many organizations have taken steps to improve medication safety. But have improvements been made in areas such as invasive radiology, GI suites, perioperative areas, or ambulatory clinics? Take a tour of these distinct locations with ISMP consulting staff to learn what unique medication safety risks have been uncovered “off the beaten path,” and how to improve safety.
  • For details on both webinars, visit: www.ismp.org/educational/webinars.asp.

  • Unique 2-day program

    Attend ISMP’s Medication Safety INTENSIVE workshop, a one-of-a-kind, interactive program that will teach you how to approach medication safety “through the eyes of ISMP.” Sharpen your risk assessment and event investigation skills, and learn more about human errors, Just Culture, Lean Six Sigma, high-leverage error-reduction strategies, and more. The workshop will be held in San Francisco, CA, on September 22-23, 2011. For details, visit: www.ismp.org/educational/MSI.

  • 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. 

June 16, 2011

  • Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization
  • Safety Brief: Nplate has confusing label
    NPLATE  (romiPLOStim) is a thrombopoietin receptor agonist available as a lyophilized powder in both 250 mcg and 500 mcg vials. Both vials are similarly labeled and do not accurately reflect the correct amount of drug. Find out more.
  • Safety Brief: Anesthesia groups ask TJC for changes.
    ISMP and the American Society of Health-System Pharmacists (ASHP) are aware of communications from several anesthesia-related professional groups asking The Joint Commission (TJC) to relax several requirements meant to assure safe injection practices. Learn more about ISMP and ASHP’s concerns.
  • Safety Brief: FDA puts limits on simvastatin
    US Food and Drug Administration (FDA) is changing simvastatin labeling to limit the use of 80 mg doses due to the increased risk of muscle damage in patients taking this dose compared to patients taking lower doses of this drug or other drugs in the same class.

Special Announcements

  • ISMP webinars
    On July 26, ISMP will present a webinar on Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. In traditional patient care units, many organizations have taken steps to improve medication safety. But have improvements been made in areas such as invasive radiology, GI suites, perioperative areas, or ambulatory clinics? Take a tour of these distinct locations with ISMP consulting staff to learn what unique medication safety risks have been uncovered “off the beaten path,” and how to improve safety.

    For details on both webinars, visit: www.ismp.org/educational/webinars.asp.

  • Unique 2-day program
    Attend ISMP’s Medication Safety INTENSIVE workshop, a one-of-a-kind, interactive program that will teach you how to approach medication safety “through the eyes of ISMP.” Sharpen your risk assessment and event investigation skills, and learn more about human errors, Just Culture, Lean Six Sigma, high-leverage error-reduction strategies, and more. The workshop will be held in San Francisco, CA, on September 22-23, 2011. For details, visit: www.ismp.org/educational/MSI.
  • 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.

June 30, 2011

  • Scanner beep only means the barcode has been scanned
  • Barcode scanning after drug administration has little value
  • National Alert Network Alert: Dosing confusion with colistimethate for injection
    ISMP and ASHP sent a warning through the National Alert Network (NAN) earlier this week about dosing errors involving colistimethate for injection, a prodrug of colistin
  • Safety Brief: Mix-ups between risperiDONE and rOPINIRole.
    FDA recently alerted the public about reports of mix-ups between risperiDONE (RISPERDAL) and rOPINIRole (REQUIP), some of which involved patients who required hospitalization.
  • Safety Brief: IV compounding services assessment tool
    For organizations that outsource IV solution compounding to an external vendor, a new tool is available to help assess vendor’s compliance with quality and safety measures and government regulations.
  • ISMP Survey on Gray Markets
    We are asking directors of pharmacy, in cooperation with their purchasing staff, to please complete our survey on page 4 and submit your responses by August 1, 2011, at: www.surveymonkey.com/s/graymarkets.
  • Don’t forget to complete your self assessment by August 31
    Complete your self assessment and submit your findings to ISMP by August 31, 2011, to be included in this critically important national effort. To access the project webpage, visit: www.ismp.org/selfassessments/Hospital/2011/Default.asp.

Special Announcements

  • ISMP webinars
    On July 26, ISMP will present Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. Take a tour of invasive radiology, GI suites, perioperative areas, and ambulatory clinics with ISMP consulting staff to learn what unique medication safety risks have been uncovered “off the beaten path,” and how to improve safety. For details, visit: www.ismp.org/educational/webinars.asp.
  • ISMP Cheers Awards!
    Nominations for this year’s ISMP Cheers Awards are now being accepted through September 8. The Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors during the previous year. For details, please visit: www.ismp.org/Cheers.
  • 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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