The following are excerpts from the newsletter
- Shedding "lyte" on the multifaceted
nature of errors
- In the mail: ISMP Medication
Safety Self AssessmentTM.
Make a difference - participate!
- Safety Briefs
- Concerns raised about the use of the name ZYVOX
and possible confusion.
- Problematic brand name, FIV-ASA (mesalamine)
may cause confusion.
- Poor handwriting of ACIPHEX caused confusion
with ACCUPRIL in recent report.
- FDA has approved LANTUS (insulin glargine [rDNA
origin]). Concern is mounting that oral or written orders
for Lantus may be mistaken as "Lente".
- The European Committee for Standardization issued
a report about the dangers of incorrect newsletters/acutecare/articles
between devices used for the vascular, enteral, respiratory,
and other body systems.
- Hospitals sometimes struggle over the meaning of the
- We say we get it, but do we really? Is it really non-punitive?
May 17, 2000
- Want a savvy participant in your
error-prevention program? Put a consumer on your team
- Technology - only as good as the user!
- Safety Briefs
- Some healthcare workers have been confusing the two
commercially available anti-thymocyte globulin products.
Both are antibodies raised in animals, which act against
lymphocytes and T-cells to suppress cell-mediated immunity.
Orders stating only "anti-thymocyte globulin" or "ATG"
must be clarified.
- No accidents have been reported yet, but Faulding's
vincristine sulfate and vinblastine sulfate products
look dangerously similar.
Picture of Faulding packages for Vincristine
- An order received by a pharmacist for REMICADE (infliximab)
was profiled and prepared as RITUXAN (rituximab).
- Please join us at the ASHP Annual Meeting in Philadelphia
to discover new horizons in technology. On Monday, June
5, 2000, 11:30 a.m. to 1:45 p.m., we will be presenting
" Technological Advances in Medication Management,"
sponsored by Becton-Dickinson. On Tuesday, June 6, 2000,
from 11:30 a.m. to 1:45 p.m., we will be presenting
"Closing the Patient Safety Loop: Technology Update,"
sponsored by Autros Healthcare Solutions. Each sponsor
is working hard to help us improve safety through the
innovative use of advanced technology. Both exhibitor's
theaters will be held in room 202 at the Pennsylvania
Convention Center. Preregistration is not required,
but seating is limited.
- A California hospital received media attention this
week for providing medical staff with a handwriting
improvement course as a way to prevent medication errors.
- There U go again: The abbreviation "IU" (international
units) in an order for "Vitamin E 100 IU daily" was
misinterpreted as IV (intravenous). This led to drawing
capsule contents into a syringe for intravenous administration.
- A complete set of
back issues of the ISMP Medication Safety Alert! (from
January, 1996) is available on CD-ROM. The material
is presented in Adobe PDF format with the Adobe Acrobat
Reader included. All articles are searchable in full
text and may be copied for internal use. Visit our web
site or call us to place an order. Purchase orders and
major credit cards are accepted.
May 31, 2000
- Mandatory reporting programs:
Why we can't "look the other way"
- Design flaw predisposes Abbott Lifecare PCA Plus II pump
to dangerous medication errors.
On Sunday, the Tallahassee Democrat (FL) reported that a
19-year-old mother died hours after a routine cesarean section
when a nurse accidentally misprogrammed an Abbott Lifecare
PCA Plus II Infusion pump.
- Safety Briefs
- A hospital recently reported two medication errors where
orders for "folinic acid" were confused with folic acid.
- New drug information database available for Palm based
PDA's at www.ePocrates.com
is available free. The application, known as ePocrates
qRx, makes important clinical information for most medications
immediately available to clinicians when it's needed.
- Gliatech, Inc. recently announced the initiation of
Phase II clinical trials for a new compound that will
be used to treat patients with attention deficit hyperactivity
disorder (ADHD). The currently proposed name may lead
to confusion. The company intends to sell the product
to a larger pharmaceutical company and anticipates a name
- The American Society of Healthcare Risk Management is
sponsoring the first-ever National Healthcare Risk Management
Week on June 19-26, 2000.
- State Senate bill 2187, recently introduced in Massachusetts,
proposes the creation of the "Betsy Lehman Center for
Patient Safety and Medical Error Reduction."