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The following are excerpts from the newsletter

March 8, 2007

  • Criminal prosecution of human error will likely have dangerous long-term consequences
  • Safe practices not evident when dispensing drug samples

    A two-phase observational study was conducted evaluating seven specific ISMP recommendations regarding safe dispensing of drug samples. Results concluded that none of the 17 urban and rural primary care practices participating in the study were compliant with ISMP recommendations. Observations found that patients were usually given verbal instructions about the appropriate use of samples and side effects; however, labeling and written patient instructions were inadequate, which may increase the risk of medication errors. 

  • Information from prior admissions helps prevent errors

    Availability and review of patient information from prior admissions at the time of prescribing, dispensing, and administration is important in preventing medication errors.

  • Working next Sunday?
  • Some medical equipment and information technology systems might display incorrect information next week as a result of the early arrival of Daylight Savings Time.

  • New oral morphine strength
  • FDA has approved KADIAN (morphine sulfate extended release) 200 mg capsules. The product is also available in 20 mg capsules. A word of caution is in order since confusion has been reported between drugs that have a ten-fold difference in strength.

  • Confusion in HIV guidelines
  • An error was made in interpreting the CDC’s HIV post-exposure prophylaxis (PEP) guideline.KALETRA (lopinavir/ritonavir) dosing in the CDC guideline is listed as “400/100 = 3 capsules bid.” Unfortunately, this may be interpreted as 3 tablets of a 400/100 strength (which does not exist) or 6 tablets of the available 200/50 mg strength (total of 1,200/300 per dose). The CDC guideline is actually referring to 3 capsules of a 133/33 strength, which is no longer manufactured in the US.

  • Just released: MEDMARX report
  • The United States Pharmacopeia (USP) Center for the Advancement of Patient Safety has released its annual report, MEDMARX Data Report: A Chartbook of Medication ErrorFindings from the Perioperative Settings from 1998-2005. The report outlines findings from an analysis of errors submitted to the program as well as safety recommendations.

Special Announcements…

  • High-alert medication survey
  • We need your help! Please help determine the ISMP high alert drug list for 2007: Visit www.ismp.org/survey/survey200702.asp to complete our survey on high-alert medications.

  • ISMP Safe Medication Management Fellowship
  • Jump start your career in patient safety:---ISMP Fellowship now accepting applications. For an application and more information, please visit: www.ismp.org/profdevelopment/managementfellowship.asp.

  • ISMP teleconference
  • Barcoding at the Point-of-Care to Enhance Medication Safety, Part I: Readiness and Implementation Strategies, March 14, 2007, with technology expert Mark Neuenschwander. http://www.ismp.org/educational/teleconferences.asp to register.

  • Educational Programs
  • Join ISMP at the unSUMMIT! Bedside Barcode Technology in Practice, May 9-11.  Basic and advanced tracks and post-conference workshop by ISMP on using bar-code point-of-care data to drive quality improvement, monitor implementation progress, and enhance medication safety. For more information or to register, visit www.unsummit.com or call 412-287-5108.

    Just Culture training. Outcome Engineering, LLC, curators of the Just Culture Community (www.justculture.org), will offer its next public course on JustCulture Training on April 17-18 in Dallas,TX. This course is the entry point for those seriously desiring to change their organizational culture through use of the Just Culture Community tools. For more information, visit: www.justculture.org/pge_publiccourse.asp.

March 22, 2007

  • If safety is your yardstick, measuring culture from the top down must be a priority
  • Propofol and Rotaglide look-alike vials
  • When preparing to sedate a patient with propofol, an anesthesiologist noticed significant resistance when he attempted to withdraw the drug into a syringe. When he inspected the vial, he saw that it actually contained ROTAGLIDE, a lipid-based emulsion used for lubrication in various surgical procedures.

  • Apothecary measurement still causing errors
  • A mother recently discovered she had been incorrectly measuring her child’s dose of ranitidine syrup. The mother had been given an oral syringe with metric and apothecary (minim) scales and had been measuring 3.5 minims (0.22 mL), rather than the correct dose of 3.5 mL, using the apothecary scale on the syringe.

  • “Dilaudid” favored over “hydromorphone”
  • A pharmacist told us about a strategy his hospital employs to eliminate hydromorphone and morphine mix-ups; his hospital totally eliminated use of the name hydromorphone from storage areas, formulary listings, computer selection screens, and computer generated medication administration records.

  • Asmanex Twisthaler video
  • FDA has produced a free medication safety-related video (Patient Safety News, March 2007) that demonstrates the problem we described regarding ASMANEX TWISTHALER (mometasone furoate) in our November 16, 2006 issue.

  • Abbreviation of concern
  • An order for a medication was received with instructions to “give q mon.” Depending on the medication, “mon” might indicate once every month, especially if the letter “m” is not capitalized, or once every Monday, especially if the M” is capitalized.

Special Announcements…

  • High-alert medication survey
  • We need your help! Please help determine the ISMP high alert drug list for 2007: Visit www.ismp.org/survey/survey200702.asp to complete our survey on high-alert medications.

  • ISMP Safe Medication Management Fellowship
  • Jump start your career in patient safety:---ISMP Fellowship now accepting applications. For an application and more information, please visit: www.ismp.org/profdevelopment/managementfellowship.asp.

  • ISMP teleconference
  • Barcoding at the Point-of-Care to Enhance Medication Safety, Part II: Lessons From the Bedside, April 4, 2007.  Janice Dunsavage, RPh, MS, from PinnacleHealth in Harrisburg, PA, provides a first-hand look at the challenges faced by an organization that has successfully implemented a barcoded drug administration system. For more information please visit:  http://www.ismp.org/educational/teleconferences.asp.

  • Educational Programs
  • Join ISMP at the unSUMMIT! Bedside Barcode Technology in Practice, May 9-11.  Basic and advanced tracks and post-conference workshop by ISMP on using bar-code point-of-care data to drive quality improvement, monitor implementation progress, and enhance medication safety. For more information or to register, visit www.unsummit.com or call 412-287-5108.

    Just Culture training. Outcome Engineering, LLC, curators of the Just Culture Community (www.justculture.org), will offer its next public course on Just Culture Training on April 17-18 in Dallas,TX. This course is the entry point for those seriously desiring to change their organizational culture through use of the Just Culture Community tools. For more information, visit: www.justculture.org/pge_publiccourse.asp.

 

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