The following are excerpts from the newsletter
March 12, 2009
- Beware of basal opioid infusions with PCA therapy
- Topical lidocaine gel and mammography
FDA issued an advisory last month (www.fda.gov/cder/drug/advisory/topical_anesthetics.htm) to remind patients, healthcare professionals, and caregivers about potentially serious hazards associated with overuse of topical anesthetics. Learn more about the potential dangers associated with these medications and safety strategies to prevent harm in the newsletter.
- Safety Brief: Purchase eye meds with care.
A pharmacy technician reported a look alike packaging issue with Bausch and Lomb’s polymyxin B and trimethoprim ophthalmic solution, and the company’s neomycin, polymyxin B, and gramicidin ophthalmic solution. The problem of packaging similarities with ophthalmic medications is related in part to FDA approval of a color-coding system by pharmacologic class, making all products within a class the same color. This is one of many examples of dangerous, confusing ophthalmic labeling mentioned in this newsletter. It reminds us that group purchasing organizations, pharmacies, and hospitals should purchase and use a different manufacturer for individual ophthalmic products within each class, whenever possible.
- Safety Brief: ISMP smart pump guidelines.
In the fall of 2008, ISMP held a national forum with pharmacists, nurses, physicians, biomedical staff, and vendors to develop consensus-driven safety guidelines for smart infusion pumps. Three key areas in which facilities consistently need direction were identified: implementation, drug library development, and maintenance and data analysis to guide clinical practice. The guidelines, which center on these topics, are available for public comment until May 11, 2009, at: www.ismp.org/tools/guidelines/smartpumps/comments/.
- In the News: Patch advisory.
FDA issued a public health advisory last week regarding transdermal patches worn during an MRI. In our April 8, 2004 newsletter, an FDA Advise-ERR noted that some patches are formulated with an aluminized backing that could cause injury to the patient if worn during an MRI. Patients have reported skin burns at the patch site when wearing a patch during an MRI. Check out the newsletter for some suggestions on how to prevent this type of injury at your facility.
- In the News: New appointment at AHRQ.
Congratulations to our colleague Diane Cousins, whohas accepted an appointment to the Agency for Healthcare Research and Quality (AHRQ) in the Center for Quality Improvement and Patient Safety beginning on March 16. We look forward to our ongoing interaction with Diane in her new position.
- ISMP teleconference.
Join us on April 16 for the second of ISMP’s four part teleconference series on high-alert medications, Reducing the Risk of Patient Harm from Anticoagulation Therapy. For details, visit: www.ismp.org/educational/teleconferences.asp.
- ISMP Safe Medication Management Fellowship.
This yearlong learning opportunity, funded by Cardinal Health Foundation, offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. Fellows have the unique opportunity to make a real difference in medication safety. Fellowship information and application can be found at: www.ismp.org/profdevelopment/managementfellowship.asp. Applications can also be requested by calling 215-947-7797 or via email@example.com. All applications must be received by March 31, 2009.
- ISMP Medication Safety Intensive.
This intensive workshop will help you look at your organization “through the eyes of ISMP” medication safety experts, who will take you though their real-world experiences in establishing and evaluating medication safety programs. Three dates are scheduled in 2009, and space is limited. For more information about the program and to register, please visit: www.ismp.org/educational/MSI.
- 10-Minute ISMP Survey on Look-Alike and Sound-Alike (LASA) Drug Names.
Please take time to complete our survey found on pages 4 and 5 of the newsletter or on our website at: www.ismp.org/survey/Survey200902.asp. We are very interested in the opinions of all staff involved in the medication use process, including unit secretaries who transcribe medication orders and pharmacy technicians who help dispense medications. Even if you know little about the topic, ISMP would sincerely appreciate your response to the survey by April 17, 2009.
march 26, 2009
- Fatal outcome after inadvertent injection of topical EPINEPHrine
A patient with a history of rheumatoid arthritis was prescribed oral methotrexate 10 mg BID on Mondays. She was admitted to the hospital and was discharged. The methotrexate was transcribed on the discharge medication list as “methotrexate 10 mg po BID” resulting in an overdose. To read more about this error see the newsletter.
- Safety Brief: Safety cap that won’t protect kids.
The US Consumer Product Safety Commission (CPSC) requires that oral prescription drugs be dispensed in child-resistant packaging unless the drug is exempted or the patient or prescriber requests otherwise. What about dual purpose caps? Learn about the requirements set in the Poison Prevention Packaging Act (PPPA) on the CPSC website at: www.cpsc.gov/BUSINFO/pppainfo.html or read more in our newsletter.
- Safety Brief: XL or x1?
We heard from a hospital employee who was proofing a dictated report and realized that the commonly used drug name suffix “XL” looked very much like x1 (times one), which could be confusing. Indeed, we once received a report about misinterpretation of an order written for “Procardia 90 mg XL” as 90 mg x1. This led to administration of nine immediate-release, 10 mg PROCARDIA (NIFEdipine) capsules and the patient’s transfer to an ICU.
- Safety Brief: FDA echoes concern about insulin pens.
An FDA alert last week warned that insulin pens and cartridges are never to be shared among patients. Sharing of insulin pens may result in transmission of hepatitis viruses, HIV, or other blood-borne pathogens. ISMP has published similar alerts on several occasions including hazard alerts in our March 27, 2008 and February 12, 2009 issues. Check out those newsletters for more information about the dangers of sharing insulin pens.
- Safety Brief: NQF Safe Practices update.
In March, the National Quality Forum (NQF) published Safe Practices for Better Healthcare—2009 Update(www.qualityforum.org/publications/reports/safe_practices_2009.asp), which includes 34 practices that have been demonstrated to be effective in reducing adverse events. The NQF safe practices have been referenced by state, federal, and accrediting agencies, the Centers for Medicare & Medicaid Services, and third-party payers to identify enforceable standards and “never events” subject to nonpayment.
- Safety Brief: NovoSeven label requires change.
The labeling for NOVOSEVEN RT (clotting factor VIIa) uses trailing zeros when expressing the dose. The 1 mg, 2 mg, and 5 mg dosages are labeled as 1.0 mg, 2.0 mg, and 5.0 mg. Learn more about the dangers of trailing zeros by reading the newsletter and viewing “ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations” available on our website http://www.ismp.org/Tools/errorproneabbreviations.pdf.
- Last call: Apply for the ISMP Fellowship. We are still accepting applications for the 2009-2010 ISMP Safe Medication Management Fellowship, funded through a grant from Cardinal Health Foundation. Learn more about this unique opportunity by visiting: www.ismp.org/profdevelopment/managementfellowship.asp. Applications must be received by March 31
- To Our Subscribers. We frequently receive requests from our subscribers for permission to distribute this newsletter to other staff in their facility. ISMP encourages, and grants permission for, internal redistribution of the ISMP Medication Safety Alert!Acute Care Edition. The newsletter is intended for practitioners who prescribe, dispense, or administer medications, as well as those who are otherwise responsible for patient safety within the subscribing facility. The material may be reprinted or redistributed electronically throughout your hospital, and selected topics should be included on clinical committee agendas in order to protect your patients from potentially harmful medication errors. However, we do not accept commercial advertising, so the operation of ISMP, including our publications, is highly dependent upon subscription income. Thus, we must emphasize: The newsletter may not be distributed throughout a multi-hospital health system; it may not be sent to individuals who are not employees or medical staff members; and it may not be posted on Internet sites accessible to others outside the specific subscribing facility. (Posting on an Intranet site accessible only to employees/medical staff is acceptable.) Thank you for respecting this request and helping to support our work. By the way, some subscribers who receive our publication by email are surprisingly unaware that a PDF version of the newsletter is attached. If so, they are missing out on color graphics and tables, and the ability to easily reprint the newsletter for internal redistribution within your facility!
- ISMP teleconference. Join us on April 16 for the second of ISMP’s four part teleconference series on high-alert medications, Reducing the Risk of Patient Harm from Anticoagulation Therapy. For details, visit: www.ismp.org/educational/teleconferences.asp.
- unSummit time again. If your hospital is planning to install bedside point-of- care (BPOC) scanning, the annual unSUMMIT for Bedside Barcoding is an excellent educational event. The program is being held May 6-9, 2009, in Tampa, FL. This forum provides an opportunity for peer-to-peer exchange and offers hospitals a way to evaluate BPOC systems and associated technologies all in one location. As always, patient safety is the overriding theme. For more information, please visit: www.unsummit.com/.
- ISMP Medication Safety Intensive. This intensive workshop will help you look at your organization “through the eyes of ISMP” medication safety experts, who will take you though their real-world experiences in establishing and evaluating medication safety programs. Three dates are scheduled in 2009, and space is limited. For more information about the program and to register, please visit: www.ismp.org/educational/MSI.
- 10-Minute ISMP Survey on Look-Alike and Sound-Alike (LASA) Drug Names. Please take time to complete our survey found on our website at: www.ismp.org/survey/Survey200902.asp. We are very interested in the opinions of all staff involved in the medication use process, including unit secretaries who transcribe medication orders and pharmacy technicians who help dispense medications. Even if you know little about the topic, ISMP would sincerely appreciate your response to the survey by
- April 17, 2009.
ISMP educational programs and symposia. As you prepare for live continuing education programs for your hospital, professional organization, or company during 2009 and beyond, please keep in mind that ISMP physicians, nurses, and pharmacists are available to speak on various topics of interest in the field of medication safety. For more information about our speakers and areas of expertise, please send an email message with an inquiry (firstname.lastname@example.org) or visit: www.ismp.org/educational/default.asp.