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The following are excerpts from the newsletter

March 10, 2011

  • Oops, sorry, wrong patient!
    A patient verification process is needed everywhere, not just at the bedside
  • Hazard Alert! Electrolyte shortages
    The national shortage of common electrolyte solutions in certain strengths and sizes has forced many pharmacists to replace their standard injectable solutions with a different product. Check out this week’s issue to find out more.
  • WorthRepeating: Anticoagulant-Plasma volume expander mix-ups
     Since October 2010, we have received four reports of mix-ups between anticoagulant and plasma volume expander products. One case occurred in the operating room (OR); where the anticoagulant was nearly administered in error to treat hypotension. Find out more about these mix-ups and how to prevent them.
  • Safety Brief: These look-alikes top our list
    We doubt that we’ve ever seen two different products that looked so much alike. It took us a few minutes, but we eventually realized that there is, in fact, a difference between syringes of a particular brand of hepatitis immune globulin. Learn more about our concerns and how to address this issue in your organization.
  • Safety Brief: Proper preparation of multi-chamber bag
    We continue to receive errors about proper preparation of multi-chamber bags, particularly from organizations that store multi-chamber total parenteral nutrition bags CLINIMIX (amino acid and dextrose) or CLINIMIX E (amino acid and dextrose with electrolytes) in their overwraps on nursing units or allow non-pharmacy personnel into the pharmacy to remove drugs after pharmacy hours. Check out this week’s newsletter to find out what steps to implement in order to prevent such errors from happening in your organization.
  • In Deepest Sympathy
    ISMP sadly notes the death on March 3 of Herbert S. Carlin, the 2005 winner of the ISMP Cheers Lifetime Achievement Award. Dr. Carlin was honored for his long history of providing outstanding leadership on medication safety issues, including influencing the safe naming and labeling of drug products through long-term service on the USP Nomenclature Committee and the FDA-USP Product Labeling Committee, serving as president or trustee for several national organizations, and for his mentoring of students.
Special Announcements
  • ISMP webinars
    April: On April 21, ISMP will present Wrong Tube-Wrong Connection: Preparing for New AAMI-ISO Standards for Healthcare Connectors. Catheter/tubing misconnections are a serious problem in healthcare. The International Organization for Standardization (ISO) has been working on standards to make various healthcare catheter fittings and associated tubing sets or syringes incompatible with one another. Please join us as industry leaders and clinicians describe the forthcoming standards, as well as actions that should be taken now to prevent misconnections and prepare for the upcoming changes.
  • May: On May 12, ISMP will present Beyond the 5 Rights: A Safety Bolus for Nursing Leadership. Are nurse leaders in your organization worried about the risk of drug administration errors? Are they concerned that the “5 Rights” alone will not keep patients safe? Don’t let a medication-related sentinel event be your wake-up call! Learn where risk is present but “hidden” in your medication administration system, and discover the high-leverage error-reduction strategies that can reduce the risk of harmful errors. For details on both webinars, visit: www.ismp.org/educational/webinars.asp.
  • Three fellowships available
    ISMP is offering three fellowships this year. The first ISMP Safe Medication Management Fellowship is the Stephen R. Lewis, MD Fellowship, sponsored by the CareFusion Foundation in memory of its former Chief Medical Officer and senior vice president of the Center for Safety and Clinical Excellence. Medco Foundation is sponsoring a second ISMP Safe Medication Management Fellowship position. Our third fellowship, the FDA/ISMP Safe Medication Management Fellowship, offers a candidate an opportunity to spend 6 months at ISMP and 6 months at the FDA. These fellowships provide unique year-long learning experiences for practitioners interested in patient safety in a challenging and rewarding environment. The fellows benefit from ISMP’s years of experience devoted to medication error prevention. At the FDA, valuable regulatory experience is gained by working with the division focused on medication error prevention. We are accepting applications for all three fellowships until March 31. For details, visit: www.ismp.org/profdevelopment/.

  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

March 24, 2011

  • Diabetes in Control.com-A website for medical professionals
  • Dosing error with new Taxotere concentration
    A patient on TAXOTERE (DOCEtaxel) received twice the intended dose. Check out this week’s newsletter to learn more.
  • Safety Brief: Triaminic brand name extension could be dangerous to kids
    A community pharmacist wrote to us about a concern he has regarding acetaminophen marketed under the Triaminic brand name, TRIAMINIC FEVER REDUCER. Find out more.
  • Safety Brief: Mix-up between PPD and polio vaccine
    A medication error occurred at an immunization clinic when a public health nurse, intending to administer a tuberculin (purified protein derivative [PPD]) skin test, mistakenly administered 0.1 mL of injectable inactivated polio vaccine (IPV) intradermally.

Special Announcements

  • Two ISMP webinars. On April 21, ISMP will present Wrong Tube-Wrong Connection: Preparing for New AAMI-ISO Standards for Healthcare Connectors. Please join us as industry leaders describe forthcoming standards from the International Organization for Standardization (ISO) that will make various catheter fittings and tubing sets or syringes incompatible with one another. On May 12, ISMP will present Beyond the 5 Rights: A Safety Bolus for Nursing Leadership. Learn where risk is present but hidden in your medication administration system, and how to reduce the risk of harmful errors. For details on both webinars, visit: www.ismp.org/educational/webinars.asp.
  • 2011 unSUMMIT. Want to refine your strategies for bedside barcoding? Attend this year’s unSUMMIT, Catching Errors at the Point of Care, in Louisville, KY, April 27-29. ISMP newsletter subscribers will receive a $50 discount; go to www.unsummit.com/ and enter the code SMP11.
  • ASHP Award applications. The ASHP Research and Education Foundation is accepting applications until April 29 for the 2011 Award for Excellence in Medication-Use Safety. The program honors a pharmacist-led interdisciplinary team for significant institution-wide system improvements relating to medication use. Recipients of the award receive $50,000, and each finalist receives $10,000. For details, visit: www.excellenceinmeduse.org.
  • Medication safety track. ASHP will be offering a Medication Safety track at the 2011 Summer Meeting on June 12-15 (Denver), with 18.5 hours of CE and CME for physicians, nurses, and pharmacists! For details, visit: www.ashp.org/summermeeting.
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication.


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