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The following are excerpts from the newsletter

March 11, 2010

  • ISMP develops guidelines for standard order sets
  • Safety Brief: Access to ambulatory lab info only includes prescribers.

    Quest Diagnostics, a provider of diagnostic
    testing, and Surescripts, a company that operates an electronic routing service that links electronic prescriptions to community pharmacies, announced an agreement to form an integrated service to make lab information accessible to physicians.  Learn what is being done to possibly expand this access to community pharmacists.
  • Safety Brief: Carton may hold multiple lot numbers and expiration dates.

    ISMP received a report indicating that an outsourced product, packaged in a CADD cassette, had been shipped in a carton that contained 5 cassettes with differing lot numbers and expiration dates.  Discover how this shipping practice may affect your pharmacy’s restocking process.
  • Safety Brief: Errors with insulin.

    In order to aid healthcare facilities in identifying and monitoring problems associated with the use of insulin, the Pennsylvania Patient Safety Authority has posted a sample tool on their Web site (www.patientsafetyauthority.org/EducationalTools/PatientSafetyTools/insulin/Pages/home.aspx) which allows organizations to document facility-specific process and outcome measures involving the use of insulin.
  • Safety Brief: Is it “units” or a 4?

    ISMP recently became aware of yet another medication error involving the error-prone abbreviation, “U.”  Learn more about this incident and other similar cases in this week’s issue.
  • Safety Brief: Root cause analysis published.

    Following the occurrence of a fatal medication error in which a patient was tragically given an infusion of epidural bupivacaine and fentaNYL intravenously, the hospital where the error occurred, invited ISMP to conduct an independent root cause analysis (RCA) of the event.  Now, in cooperation with hospital leadership, the analysis appears in the March 2010 issue of The Joint Commission Journal on Quality and Patient Safety.  
  • Safety Brief: Free medication safety videos.

    The latest medication error-related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading at:
    www.ismp.org/Tools/fdavideos.asp.
  • Your Reports at Work: KAPIDEX is now DEXILANT.

    Last year, soon after the proton pump inhibitor KAPIDEX (dexlansoprazole) was marketed, FDA and ISMP began to receive reports that Kapidex was being confused with CASODEX (bicalutamide). Last week FDA and Takeda Pharmaceuticals announced that DEXILANT will be the new brand name for Kapidex to improve safety.

Special Announcements

  • Upcoming ISMP webinars. 

    • March 23, 2010: Measuring up to medication safety: Where do you stand? Measuring the level of safety is fundamental to improvement. Yet, measuring medication safety has long been a challenge. Join ISMP to learn about the methods you can use to effectively measure medication safety in your organization and determine whether your improvement efforts are successful. For details and to register, visit: www.ismp.org/educational/webinars.asp.

    • April 22, 2010:Bring Quarterly Safety Action Agendas to Life (First Quarter 2010).  ISMP’s Action Agendas, presented quarterly in its acute care newsletter, give hospitals information on current medication safety problems, prevention recommendations, and a framework to create an ongoing process for reviewing risks and avoiding harmful events.  Now an ongoing series of ISMP Action Agenda webinars led by ISMP’s President Michael R. Cohen can help you bring your medication safety review process to life and support your existing medication safety agenda. To register, please visit: www.ismp.org/educational/webinars.


March 25, 2010

  • California Department of Public Health Medication Error Reduction Plan
  • Safety Brief: Look-alike Sandoz antibiotics.

    A pharmacist reported an error involving two look-alike Sandoz antibiotics.  Read more about the two products involved in this week’s issue.
  • Safety Brief: e-Rx error.

    ISMP recently received an example of a potential error caused by an electronically generated prescription form, which in this instance resulted in the prescription directions being entered into the pharmacy computer incorrectly.  If you have examples of errors with electronic prescribing systems both in the acute care and ambulatory settings, please report them to ISMP through our Medication Errors Reporting Program (MERP), which can be accessed at: http://www.ismp.org/orderforms/reporterrortoismp.asp (or you can send an email message to: ismpinfo@ismp.org).

  • Safety Brief: A three-in-one package insert?

    While consulting the package insert for a product, a pharmacist discovered that the package insert actually contained drug information about three different products.  Find out which three products were involved, in order to determine if this could be a source of error within your organization.

  • In the News: Genetic testing and warfarin dosing.

    A study by researchers from Medco Health and Mayo Clinic, which will be published in the

    Journal of the American College of Cardiology, showed that hospitalization rates due to adverse drug events in cardiac patients taking warfarin dropped by approximately 30% when genetic information was available to doctors prescribing the drug.  Learn more about this research in this week’s issue.

Special Announcements

  • Free webinar.

    ISMP has reviewed and aggregated data for key areas addressed in the ISMP Medication Safety Self Assessment for Antithrombotic Therapy in Hospitals. A free webinar to discuss the results will be held on both April 27 and April 29, 2010. You can register for the webinar at: www.pharmacyadvisor.com. The webinar is one of several featured in a section called “In the Bin” (right side of the home page screen).

  • New ISMP webinar series.

    Join ISMP for an ongoing series of ISMP Action Agenda webinars designed exclusively for pharmacy and therapeutics or safety committees to bring your medication safety review process to life. The first webinar on April 22 is offered at a significant discount so you can see how these sessions, led by ISMP President Michael R. Cohen, can help advance your medication safety agenda and help you meet several Joint Commission standards. For details and to register, visit: www.ismp.org/educational/webinars.



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