The following are excerpts from the newsletter
- The virtues of independent double
checks they really are worth your time!
- New color code for 25 gauge safety needles may lead
to confusion and errors - Problems with a TB syringe
(25 gauge needle affixed) that is color-coded with an orange
plunger cap and label, the same color used on insulin syringes
and vial caps.
- Worth Repeating - People often seem hesitant when
we suggest that they designate volume only in mL, not in
cubic centimeters (cc). But theres good reason for
making this recommendation: the abbreviation cc
has been misinterpreted repeatedly.
- More on sterile water for injection - Failure
to recognize the danger of infusing plain sterile water
IV seems to be more widespread than we thought.
- Bar-coding teleconferences - If your medication
safety team has been talking about the use of a bar-coded
drug administration system as one of your approaches to
reduce medication errors, consider joining us for a series
of live teleconferences presented on April 3, 8, 17, and
24. Along with several nationally recognized experts, well
provide independent, objective information about currently
available bar-code systems, assessment of readiness, implementation
strategies, tips and time savers, what works and what doesnt,
and much more. Visit our web site at http://www.ismp.org/RTB/index.htm
to register and for additional information on topics and
speakers for each program. Its an important conference
series you wont want to miss.
to the ISMP Medication Safety Contest winners! In
January, we invited subscribers to join us in celebrating
National Patient Safety Week in March by participating in
a contest about involving patients and the community in
medication safety initiatives. The following health systems
submitted winning entries; Fletcher Allen Health Care
in Burlington, VT., Gunderson Lutheran in La Crosse, WI.,
and Aurora Health Care from Milwaukee, WI.
- Safety Briefs
- Beware of mistaking aripiprazole (ABILIFY) for a proton
pump inhibitor (PPI).
- The labels on newer bottles of INFANTS TYLENOL
CONCENTRATED DROPS (acetaminophen) do not include the
- Lack of proper spacing between the order date (12-24-02)
and the insulin dose (6 units) nearly led to an error
- A New & Improved formulation of the
brand KAOPECTATE is available with bismuth subsalicylate
replacing attapulgite as its active ingredient.
- Two extra doses of oral colchicine 0.6 mg were given
to a patient when the abbreviation PC was
used to signify that a daily dose should be given after
one meal each day
Matters - ISMP is excited to announce that
we will be publishing a newsletter written especially
for front-line nurses. Called the ISMP Medication Safety Alert! Nursing Matters, this monthly, two-page newsletter
will be offered free to nurses during 2003 through a unrestricted
grant by Eli Lilly and Company used to fund the start-up
of this important publication. While the drug safety issues
covered in the ISMP Medication Safety Alert! Acute Care
edition are certainly applicable to nurses, anecdotal
evidence suggests that crucial medication safety information
may not be reaching very busy front-line nurses who are
continuously overwhelmed with information related to a
wide variety of important issues. Through its unique design,
its anticipated that nursing matters will be just
the vehicle needed to deliver medication safety information
to nurses who administer medications. To determine its
success, we will be using focus groups and surveys to
evaluate the interest, value, and impact of nursing matters,
and the best way to distribute important medication safety
information to nurses in the future. ISMP plans to distribute
the monthly newsletter by e-mail to a single nursing representative
in each hospital or health system, who will take responsibility
to distribute the newsletter to all front-line nurses
in the organization. Please have a representative from
your hospital or health system visit our web site later this week to subscribe to this free publication.
- Last week was National Patient
Safety Week - and what a week it was!
- Even more about sterile water! - Reports about
errors and near misses involving IV infusion of sterile
water for injection continue to arrive.
- Safety Brief
- Confusion between ZETIA (ezetimibe) and ZESTRIL
- Patients still need short-acting insulin along with
LANTUS (insulin glargine, Aventis) to ensure
proper glycemic control.
- Watch out for Abbott's labetalol injection and ESI
Lederle's DOPRAM (doxapram) vials, especially
in the OR, for look-alike confusion.
- Sound-alike alert! Recent reports indicate confusion
between RECOMBIVAX HB (hepatitis b vaccine, recombinant)
and COMVAX (haemophilus b conjugate vaccine with
hepatitis b vaccine).
- More precautions for the "New & Improved"
KAOPECTATE. The bismuth subsalicylate can lead
to darkened or black-colored stool.
- ISMP bar code teleconference
series - Last week's announcement by the federal
government about new requirements for bar codes on all pharmaceutical
packages will, no doubt, stimulate the implementation of
this technology. So don't forget to register for the ISMP
bar-code teleconference series starting April 3, 2003, and
continuing on April 8, 17, and 24. The series will provide
your medication safety team with objective information about
currently available bar-code systems, assessment of readiness,
implementation strategies, tips on what works and what doesn't,
and much more. Visit our web site at www.ismp.org
to register and for information on topics and speakers for
each program. It's an important conference series you won't
want to miss.
- Sign up for
ISMP's newest newsletter: ISMP NurseAdvise-ERR -
Over 1,000 locations have already registered to receive
a complimentary subscription to our latest newsletter designed
especially for front-line nurses. Starting April, this monthly
newsletter will be sent by e-mail to a nursing representative
at each site who then will redistribute it to all nurses
in the organization. While we originally envisioned calling
this newsletter Nursing Matters, we have changed its name
to the ISMP Medication Safety Alert! Nurse Advise-ERR to
better reflect its purpose - to provide nurses with practical
advice on how to prevent medication errors. The newsletter
will be offered free during 2003 through an unrestricted
grant from Eli Lilly and Company. There is still time to
register by visiting our web site at