ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook
Site Search by PicoSearch. Help

The following are excerpts from the newsletter

may 6, 2010

  • Preventing errors when administering drugs via an enteral feeding tube
  • Medical Device Actions: Infusion pump safety issues.
    Several patient safety issues have surfaced recently regarding two widely-used infusion pumps, Baxter Colleague Volumetric Infusion Pumps and Hospira Symbiq.  Learn what is being done to address these specific safety concerns and what the FDA is doing to improve infusion pump safety in general.
  • Safety Brief: Total amount may be misread.
    The per mL concentration listed on a unit dose cup product could easily be mistaken as the total drug content. Check out this week’s issue to learn which unit dose cup product could possibly lead to confusion.
  • Safety Brief: Lot number documentation helps detect vaccine errors.
    A nurse realized that she had given a patient the wrong vaccine while documenting the lot number of the administered dose.  Read more about this specific incident and strategies that your organization can implement in order to reduce the risk of vaccine mix-ups.

Special Announcements

  • ISMP Webinar. Join us on June 30th for a special webinar that taps into the heart of ISMP staff’s expertise in medication safety, Experiences from the ISMP Consulting Team. This highly-trained interdisciplinary team has been invited into hundreds of hospitals across North America to assess risk and provide individually tailored support for medication safety improvements. Join the consulting team as they describe ISMP’s Proactive Risk Assessment process, discuss common but serious system-based risks encountered in most hospitals, and share innovative and proven best practice recommendations organizations can implement. To register, visit: www.ismp.org/educational/webinars.

    Two new Medication Safety Self-Assessment tools. 

    • ISMP received a grant from the Commonwealth Fund to distribute an updated 2010 ISMP Medication Safety Self Assessment® for Hospitals. Building upon ISMP’s 2000 and 2004 self-assessment tools, the updated version will include many of the prior self-assessment items as well as new items associated with changes in healthcare during the past 6 years. Hospitals that used the prior self-assessment tools will be able to compare their prior scores to current scores to evaluate improvement. The new assessment tool will be distributed late in 2010.
    • ISMP, ISMP-Canada, and the International Society of Oncology Pharmacy Practitioners (ISOPP) will launch a new self assessment in 2011 to help hospitals and ambulatory cancer centers throughout the world evaluate oncology medication safety. This self assessment is supported through a grant from ISOPP. The Clinical Excellence Commission of New South Wales, the Australian Commission on Safety and Quality in Health Care, and the Cancer Institute of New South Wales will also provide grant support and expertise for the project. ISOPP received private sector support from Baxter Corporation, ICU Medical, Inc., Pfizer Oncology, and Roche.

may 20, 2010

  • Safe practice with the potent once daily opioid Exalgo
  • Worth Repeating…Prevent vinCRIStine wrong route injections
    ISMP recently learned about another fatal event where IV vinCRIStine was accidentally given into the central nervous system. Read more about this specific incident in this week’s issue.  For recommended safety strategies, please review our February 23, 2006 newsletter article, IV vinCRIStine survey shows safety improvements needed (http://www.ismp.org/Newsletters/acutecare/articles/20060223.asp) as well as the World Health Organization’s alert on this topic (http://www.who.int/medicines/publications/drugalerts/Alert_115_vincristine.pdf).  
  • Safety Brief: Confused drug names reported from November 2009 through February 2010.
    Check out this week’s issue for a list of confused drug name pairs reported to the ISMP

    Medication Errors Reporting Program (ISMP MERP) from November 2009 through February 2010.

  • Safety Brief: Another fatal event with IV bupivacaine.
    This week’s issue reviews yet another fatal event involving the administration of bupivacaine intravenously.

  • Safety Brief: Report bad advertising.
    The FDA’s Division of Drug, Marketing, Advertising, and Communications (DDMAC) launched its Bad Ad Program (www.fda.gov/badad) on May 11. FDA is asking practitioners to report misleading prescription drug promotion by calling (877) RX-DDMAC (877-793-3622) or emailing a summary of the incident to BadAd@fda.gov. If you are unsure about what constitutes misleading promotion, please call DDMAC at (301) 796-1200.

  • Message in our mailbox: Medications via enteral feeding tubes.
    Several readers asked about our reference to ACCUPRIL (quinapril) and ZAVESCA (miglustat) in our May 6, 2010, article on Preventing errors when administering drugs via an enteral feeding tube, given that neither drug is on the Do Not Crush list posted on our Web site.  Please see this week’s issue for a discussion as to why Dr. John F. Mitchell, PharmD, FASHP, who compiled and regularly updates the Do Not Crush list, has decided to not add these two drugs to the list at this time.  

Special Announcements

  • ISMP Webinar:Join us on June 30 for a special webinar that taps into the heart of ISMP staff’s expertise in medication safety, Risks encountered during ISMP hospital safety assessments. ISMP’s interdisciplinary consulting team has been invited into hundreds of hospitals across North America to assess risk and provide individually tailored support for medication safety improvements. Join the consulting team as they discuss common but serious system-based risks encountered in many of these hospitals, and share innovative and proven best practice recommendations that organizations can implement. To register, please visit: www.ismp.org/educational/webinars.asp.

subscribe now

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Survey Results
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officer Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP