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THE FOLLOWING ARE EXCERPTS FROM OUR NEWSLETTER

May 3, 2007

  • Action needed to prevent dangerous heparin-insulin confusion
  • NHS takes action on tubing misconnection issue
  • The National Patient Safety Agency (NPSA) in the United Kingdom has done something that should serve as an example for regulatory authorities and manufacturers in the US: they have set deadlines for National Health Service (NHS) entities to adopt enteral feeding catheters that do not contain ports with female Luer connectors.

  • Sound familiar? Look-alike heparin vials
  • A pharmacist who was checking medications destined for an ADC found 10 mL vials of heparin 5,000 units/mL mixed in with 10 mL vials of heparin 1,000 units/mL.

  • Sorting things out. Alphabetical versus numerical sorting
  • In an outpatient pharmacy, a prescription for SINEQUAN (doxepin) 100 mg was dispensed instead of the correct strength of 10 mg. The pharmacy software system may have played a role in the error. Upon entering “Sinequan” on the product line, the list of matching results placed 100 mg on the first line followed by 10 mg.

  • Consumer medicine record
  • FDA has developed a medicine record to help patients keep track of prescription and over-the-counter drugs and dietary supplements they use. Called, “My Medicine Record” the tool is intended to facilitate the exchange of this information with healthcare professionals so records can be updated during patient encounters.

Special Announcements…

  • Educational Programs
  • Join ISMP at the unSUMMIT! Bedside Barcode Technology in Practice, May 9-11.  Basic and advanced tracks and post-conference workshop by ISMP on using bar-code point-of-care data to drive quality improvement, monitor implementation progress, and enhance medication safety. For more information or to register, visit www.unsummit.com or call 412-287-5108.

  • Teleconference
  • Please join ISMP for a two-part teleconference entitled, “Smart Infusion Pumps: Strategies for Selecting, Implementing and Identifying Risk.” Part I will be held on June 6, 2007 from 1:30 to 3:00 PM ET and Part II will be held on June 21, 2007 from 1:30 to 3:00 PM ET. In Part I, ISMP’s Matt Grissinger and ECRI Institute’s Erin Sparnon will review errors that have been associated with the use of standard infusion pumps and discuss the technology behind smart pumps. In Part II, John Mitchell from the University of Michigan, will provide help from the perspective of a health system that has successfully employed smart infusion pump technology. Please visit www.ismp.org/teleconferences/tc2.asp to register for this teleconference.


May 17, 2007

  • ISMP 2007 survey on HIGH-ALERT medications
    Differences between nursing and pharmacy perspectives still prevalent
  • Root Cause Analysis (RCA) available
  • A woman with advanced nasopharyngeal carcinoma died after a medication event at the Cross Center Institute in Edmonton, Alberta, Canada. The woman had inadvertently received an infusion of fluorouracil over 4 hours instead of 4 days. Subsequent to the incident, ISMP Canada, was invited to perform a RCA, as an agent of Cross Cancer Institute's Medical Quality Assurance Committee. To promote learning from the ISMP Canada RCA, the Alberta Cancer Board has taken an exceptional step by publishing the full report on its website at: www.cancerboard.ab.ca.

  • Textbook errata
  • An error has been reported in the dose of REQUIP (ropinirole) for Restless Legs Syndrome listed in the Mosby's Drug Guide for Nurses, 7th Edition, under the Dosage and Routes heading. The dose currently reads: Adult: PO 25 mg at bedtime, may increase until symptoms resolve. It should read: Adult: PO 0.25 mg at bedtime.

  • AHRQ releases its first report on hospital safety culture
  • The Agency for Healthcare Research and Quality (AHRQ) released the results of the 2007 Hospital Survey on Patient Safety Culture: Comparative Database Report (www.ahrq.gov/qual/hospsurveydb/). This public report presents results from the first compilation of aggregated national data from AHRQ's Hospital Survey on Patient Safety Culture.

  • Identify-A-Bowl
  • The IDENTIFY-A-BOWL basin by Medi-Dose has a wide horizontal flange that provides a large labeling area easily seen by practitioners (see photo) to help avoid catastrophic mix-ups of solutions.

Special Announcements…

  • Teleconference
  • Please join ISMP for a two-part teleconference entitled, “Smart Infusion Pumps: Strategies for Selecting, Implementing and Identifying Risk.” Part I will be held on June 6, 2007 from 1:30 to 3:00 PM ET and Part II will be held on June 21, 2007 from 1:30 to 3:00 PM ET. In Part I, ISMP’s Matt Grissinger and ECRI Institute’s Erin Sparnon will review errors that have been associated with the use of standard infusion pumps and discuss the technology behind smart pumps. In Part II, John Mitchell from the University of Michigan, will provide help from the perspective of a health system that has successfully employed smart infusion pump technology. Please visit www.ismp.org/teleconferences/tc2.asp to register for this teleconference.

  • Employment Opportunities
  • NURSE: ISMP is seeking a full-time RN with at least 7 years combined clinical and managerial experience, to support its consulting group. Enjoy high job satisfaction as a medication safety expert, while providing support to healthcare professionals and leaders. Applicant must relocate to the Huntingdon Valley, PA, area (Philadelphia suburb) and be able to travel with our consulting team. BSN required; Masters degree and risk management or patient safety experience preferred. Send your resume by fax (215-914-1492) or email (ismpinfo@ismp.org) to Susan Paparella. For more information, visit: www.ismp.org/jobline/joblist.asp?jobType=I.

    PHARMACIST: Med-E.R.R.S., a subsidiary of ISMP that performs medical product labeling, packaging, and trademark testing, is seeking a full-time, experienced pharmacist to fill a position as a Medication Safety Analyst. This person will work on medication safety-related projects for pharmaceutical and healthcare industry clients. The position requires at least 5 years experience and excellent clinical, drug information, writing, communication, and interpersonal skills. Pharmaceutical industry experience is a plus. Email (info@med-errs.com) or fax (215-914-1492) or your resume to Susan Proulx.

May 31, 2007


  • Remote CPOE error- a situation that’s more than remotely possible
  • HydromorPHONE alert.
  • The Massachusetts Board of Registration in Medicine Patient Care Assessment Committee has issued an advisory in response to adverse outcomes associated with hydromorPHONE. 

  • Staff unaware of fentanyl patch starting doses.
  • An elderly patient received a ten-fold overdose of fentanyl via transdermal patch.  Factors contributing to the error included poor penmanship by the prescribing provider and failure to investigate an atypical starting dose. 

  • Oral solution given IV.
  • Two patients in an Emergency Department received IV infusions containing oral ondansetron liquid even though it was an oral syringe. 

Special Announcements…

  • Nominations for ISMP CHEERS Awards
  • Nominations are being accepted for the 9th Annual ISMP Cheers Awards. Self nominations are encouraged. For more information. Click here for more information.

  • Patient Hand-off Tool Kit available from AORN
  • AORN has released a web-based tool kit to improve hand-off communication in perioperative settings.  Access the tool kit by visiting www.aorn.org/toolkit/patienthandoff.

  • Teleconference
  • Please join ISMP for a two-part teleconference entitled, “Smart Infusion Pumps: Strategies for Selecting, Implementing and Identifying Risk.” Part I will be held on June 6, 2007 from 1:30 to 3:00 PM ET and Part II will be held on June 21, 2007 from 1:30 to 3:00 PM ET. In Part I, ISMP’s Matt Grissinger and ECRI Institute’s Erin Sparnon will review errors that have been associated with the use of standard infusion pumps and discuss the technology behind smart pumps. In Part II, John Mitchell from the University of Michigan, will provide help from the perspective of a health system that has successfully employed smart infusion pump technology. Please visit www.ismp.org/teleconferences/tc2.asp to register for this teleconference.

  • Employment Opportunities
  • NURSE: ISMP is seeking a full-time RN with at least 7 years combined clinical and managerial experience, to support its consulting group. Enjoy high job satisfaction as a medication safety expert, while providing support to healthcare professionals and leaders. Applicant must relocate to the Huntingdon Valley, PA, area (Philadelphia suburb) and be able to travel with our consulting team. BSN required; Masters degree and risk management or patient safety experience preferred. Send your resume by fax (215-914-1492) or email (ismpinfo@ismp.org) to Susan Paparella. For more information, visit: www.ismp.org/jobline/joblist.asp?jobType=I.

    PHARMACIST: Med-E.R.R.S., a subsidiary of ISMP that performs medical product labeling, packaging, and trademark testing, is seeking a full-time, experienced pharmacist to fill a position as a Medication Safety Analyst. This person will work on medication safety-related projects for pharmaceutical and healthcare industry clients. The position requires at least 5 years experience and excellent clinical, drug information, writing, communication, and interpersonal skills. Pharmaceutical industry experience is a plus. Email (info@med-errs.com) or fax (215-914-1492) or your resume to Susan Proulx.

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