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The following are excerpts from the newsletter

March 6, 2002

  • ISMP survey shows drug companies providing fewer unit dose packaged medications
  • Cutting errors out of the operating room
    The conditions surrounding medication administration in the surgical arena pose unique challenges that may increase the risk of errors. Many times, the clinician prescribing the medication is also the one dispensing and administering it, leaving little chance to detect an error before it reaches the patient. In other cases, even if one clinician prescribes a drug and another administers it, communication of the order typically is verbal. Such was the case reported to ISMP last week.
  • Safety Briefs
    • PCA means patient controlled analgesia. Importantly, it does not mean family-controlled, visitor-controlled, or clinician-controlled analgesia. Sometimes we lose sight of this and, occasionally, serious adverse events result.
    • In observance of National Poison Prevention Week (March 17-23), the Council on Family Health (CFH) is urging everyone to post the new, national, toll-free number for Poison Control Centers (1-800-222-1222) on appropriate telephones.
    • Poison control centers have been an excellent source of life-saving information. Just this week, we heard from a pharmacist who, without Poison Control, might not have recognized that a patient was experiencing Seratonin Syndrome. But keep in mind that, even Poison Control can make an occasional error.
    • What is the average number of MAR pages devoted to each patient at your institution? If the answer is, "Too many to be safe," one reason may be the misuse of preprinted orders.
    • Next week, March 10-16, is National Patient Safety Awareness Week. This important campaign is designed to show that health care professionals and consumers both play an important role when it comes to improving patient safety. Information, including safety fact sheets, is available at www.npsf.org.

March 20, 2002

  • Practitioner access to the Internet: A necessity in a modern hospital
  • Cutting errors out of the operating room - Part II - Medication errors during surgery often go unreported because their effects can be detected and quickly reversed before permanent patient harm. Yet, lately, we’ve received quite a few reports of medication errors that have occurred in the operating room (OR). In our last newsletter, we described an error during surgery related to verbal orders. Today, we report on several errors related in some part to the labeling or packaging of medications.
  • Safety Brief
    • In our last issue, we wrote about the potential for overdosing patients with opiates when family members activate patient controlled analgesia (PCA). Although it is not PCA, nurse controlled analgesia using a PCA infusion device may be used in some settings.
    • To help alert pharmacists that they are dealing with medication orders for pediatric patients, some hospital pharmacies use a dedicated fax machine that prints the orders on lightly colored paper (e.g., pink).
    • A nurse called the pharmacy to ask for a morning dose of DIPRIVAN (propofol) that was "missing." When the nurse showed up to pick up the medication, the pharmacist learned that the missing drug was being used for bladder spasms. The pharmacist then realized the patient was on DITROPAN (oxybutynin chloride).
    • An order for a hospitalized patient was written for "Viokase 8 tabs" with meals three times daily. To avoid misunderstanding, a pharmacist quickly intervened to make sure that a VIOKASE 8 (pancrelipase) tablet was used, not eight tablets of Viokase
    • Coming April 22-24, 2002! The National Patient Safety Foundation is holding its fourth Annenberg conference, Patient Safety: Let's Get Practical, at the Indianapolis Marriott Downtown. This event, convened by leading healthcare, management, government, and consumer advocacy groups (including ISMP), will focus on understanding a culture of safety and the individual and shared accountability necessary for achieving such a goal.

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