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The following are excerpts from the newsletter

  • Nix the quick fix: Drug protocols require groundwork
  • The dawn of the HIPAA privacy rule should not leave healthcare providers in the dark - The Health Insurance Portability and Accountability Act (HIPAA) privacy rule took effect on April 14. One particularly troubling area of confusion is whether listing the drug's intended purpose on a prescription violates HIPAA.
  • Safety Briefs
    • Hazard Alert! - Confusion between tetanusdiphtheria toxoid (Td) and tuberculin purified protein derivative (PPD) led to unnecessary treatment.
    • Precisely wrong - The order below illustrates what can happen when healthcare professionals pay attention to exact dosing without considering how the order appears when communicated.

    • Worth Repeating... Again! - Last week, New Jersey news media revealed another vincristine fatality when a radiologist gave the patient vincristine intrathecally instead of cytarabine after performing a lumbar puncture.
    • The default code for route of administration led to an error. A pharmacy order entry system used a common drug information database, which assigned "IJ" as the default route code for all "injectable" products.
    • Message in our mailbox: After reading the article on epinephrine - ephedrine mix-ups ("Looks" like a problem: ephedrine - epinephrine. ISMP Medication Safety Alert!April 17, 2003), Stein Lyftingsmo from Hospital Pharmacy of Elverum, Norway, reminded us that adrenaline is the approved name for epinephrine in Great Britain.
    • Gear up for the 2004 Joint Commission Medication Management Standards - Learn first-hand about the new JC Medication Management standards and the novel approach to the survey process beginning in 2004 from Darryl S. Rich, PharmD, MBA, Associate Director, Survey Management and Development for the Joint Commission. On July 1 and July 8, 2003, ISMP will host a two-part teleconference on these topics, with ample time to answer your questions. Dr. Rich receives and answers scores of questions each month about standards interpretation, and authors a column on Joint Commission issues in Hospital Pharmacy. You can't go wrong by learning about the standards and survey process from one of the most knowledgeable sources on the topic! We'll have more details about the teleconferences in our next newsletter, but for now, reserve the dates.

May 15, 2002

  • Oral vancomycin does not treat systemic infections - Over the years, we've heard of patients who were treated with IV vancomycin for systemic infections and then erroneously discharged on the oral form, and we continue to receive such reports.
  • Safety Briefs
    • A more flexible daily dose regimen for LANTUS insulin glargine could increase confusion with LENTE.
    • Learn about how one hospital's use of clever label design has led to safer medication practices.
    • Investigation of naloxone use uncovered an error in converting oral hydromorphone to the IV route.
    • Learn about an error that occurred because the pharmacy computer had no dose limits for digoxin.
  • Special Announcements
    • Public workshop on premarket drug name safety testing - On June 26, 2003, FDA, ISMP and the Pharmaceutical Research and Manufacturers of America (PhRMA) will be co-sponsoring a public workshop entitled "Drug Naming Approaches - Improving Patient Care by Reducing Errors."
    • ISMP teleconferences on new Joint Commission standards - On July 1 and 8, 2003, ISMP will host a two-part teleconference series on the Joint Commission's 2004 Medication Management Standards, the new approach to the accreditation process, and an update on the National Patient Safety Goals.
  • Worth Repeating - Tragedies involving chloral hydrate use in the pediatric population continue to be reported.
  • Message in our mailbox - Marva Tschampel and Mary Beth Shirk, pharmacists at Ohio State University Hospital in Columbus, wrote to warn against "on demand" dispensing of medications based solely on requests for "missing doses."

May 29, 2002

  • Thrombolytic alphabet soup: A recipe for disaster - We have received several reports recently involving mix-ups between the different thrombolytic agents.

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