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The following are excerpts from the newsletter

June 2, 1999

  • Medication error prevention "toolbox"
  • "Rule of 6" not optimal for patient safety
  • Safety Briefs
    • Problems with small amounts of medication in amber oral syringes.
    • CIPRO (ciprofloxacin) suspension, TAXOTERE (docetaxel) injection, and ROTASHIELD (rotavirus vaccine, live oral) are all packaged with product diluent that has accidently been dispensed instead of the final reconstituted drug! Contributing to the problem is that in each case the diluent container label emphasizes the name of the active drug - not the fact that it is only the diluent!
    • Pictures of these products appear below


      cipro oral suspension
      Cipro diluent on right confused with drug container on left

      rotavirus
      Diluent on right given to two babies prior to mixing with active vaccine powder on left

      taxotere
      Two views of diluent container packaged with TAXOTERE.
      Used by itself in error. 
    • Pfizer warns European health professionals of rare cases of severe and unpredictable liver injury with TROVAN (trovafloxacin).
    • Muro enhances labeling of PRELONE SYRUP (prednisolone) now that the product is marketed in two strengths to lessen chances of error.
    • Report of antibiotic suspension being reconstituted with a methadone solution.
    • New label format by Schein will prevent dispensing errors between acetahexamide and acetazolamide.


    • Sample of new acetazolamide label

June 16, 1999

  • Survey of automated dispensing shows need for practice improvements and safer system design.
  • Patients must demonstrate comprehension of medication instructions.
  • Safety Briefs
    • Hospitals using IVAC infusion pumps should be aware that some of the check valves used for piggybacking with IVAC administration sets may be difficult to prime, thus preventing gravity flow of IV solutions during IV set priming.
    • Reports of problems prompt McNeil Consumer Healthcare to begin distributing TYLENOL concentrated drops in a new container designed to help prevent accidental overdoses. The new bottle, referred to as the SAFE-TY-LOCK package, has floppy cusps within its neck ) that admit a dropper into the container, but act as one way valves, preventing gravity flow of the concentrate suspension out of the container and making it difficult or impossible to pour out teaspoonful amounts.
    • Ty-Lock picture
      Picture of SAFE-TY-LOCK mechanism.
    • Janssen Pharmaceutica has revised warnings for PROPULSID.
    • The Committee for Proprietary Medicinal Products in Europe is recommending that the license for oral and IV TROVAN be suspended.
    • Have an idea for us? We'd like your input on services and products that would support your error prevention efforts. Call Mike or Judy at 215 947 7797 or e-mail ismpinfo@ismp.org.

June 30, 1999

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