The following are excerpts from the newsletter
- A multidisciplinary team is
essential to medication error reduction efforts
- High-dose lorazepam infusion and propylene glycol toxicity
- Safety Briefs
- Potential look-alike confusion exists between Novaplus
brand atracurium injection, a neuromuscular blocker,
and Novaplus diltiazem injection, a calcium channel
- Abbott Laboratories' metoclopramide injection 10 mg
per 2 mL, packaged in 2 mL CARPUJECT boxes, looks similar
to Carpuject metoprolol 5 mg/5 mL.
- ADRENALIN Chloride Solution (epinephrine) for topical
application is in danger of being confused with Adrenalin
Chloride Solution for hypodermic use.
- The Pharmaceutical Research and Manufacturers Association
(PhRMA) has formed a 10-member task force and has identified
six issues to explore to help practitioners and patients
prevent medication errors.
- Current instructions for preparing SPORANOX (itraconazole)
IV are a bit unusual and can easily result in a dosing
- Drug reference publishers and practitioners are encouraged
to use a new ISMP web site service, "Textbook Errata."
The site, which can be accessed from the main menu on
our home page (www.ismp.org), lists corrections when
a dosing error or other serious error has been identified
in a published article or textbook. Publishers have
been encouraged to contact ISMP about textual or content
errors so they can be quickly communicated on our web
site. All reports of such errors that are sent to the
USP-ISMP program automatically will be included.
- PROCANBID (procainamide extended release) 500 mg twice
a day was dispensed when a poorly handwritten order
for probenecid 500 mg bid was misread.
- A bibliography
of over 130 articles on medication safety has been added
to the list of menu options on our web site (www.ismp.org).
Specific references are listed for focused areas such
as pediatrics, automation, failure mode and effects
analysis, research-based medication error rates, educational
materials, and general reference articles. We will update
the bibliography regularly through ongoing review of
the literature and include the most significant scientific
(theoretical and empirical) and practice-related contributions.
If you are aware of an important reference that is not
listed in the bibliography, please contact us. If possible,
fax the article or abstract to 215 914 1492.
- Caution: By coincidence, a lot number reading "8 KCL"
appears in red, bolded, upper case characters on the
reverse side of the unit dose foil package of MYCELEX
TROCHE (clotrimazole) 10 mg. The product is manufactured
by Bayer Corporation but distributed by Alza Pharmaceuticals.
On a line below "8 KCL" the characters "E 1101" also
appear. We've notified the manufacturer.