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The following are excerpts from the newsletter

May 8, 1996

  • Low molecular weight, Big potential problem.
  • Frequent errors in drug computations require a dose verification process with independent checks
  • Inadvertent heparin overdose due to improper flushing of temporary IV hemodialysis catheter
  • Safety Briefs:
    • WARNING! The injection port of B. Braun Medical's SAFSITE Reflux Valve needleless system is intended to accommodate blunt point cannulas such as the one on Tubexes. However, it also accommodates the tip of a Baxa Oral Syringe, used for unit dosing oral liquids.
    • The KePRO newsletter recently offered readers a hospital corrective action plan for preventing cancer chemotherapy drug overdoses.
    • Advice on minimizing patient risk associated with processing chemotherapy orders has been published in Am J Health-Syst Pharm, April 1, 1996.
    • A small group of hospital pharmacists has asked Abbott Laboratories to address a problem involving programming of Abbott PCA Plus II Infusor pumps that use prefilled cartridges of morphine in either 1 mg/mL or 5 mg/mL concentrations.
    • Medical examiner confirms inadvertent overdose of topical lidocaine as cause of death.

May 22, 1996

  • Improperly compounded IV fluids given to six children in two separate US incidents
  • Action needed: Up to 1/3 of pharmacists still missing Seldane® interactions
  • NPH Given IV In Error
  • Chloral Hydrate Related Pediatric Death Latest In A Series
  • Safety Briefs:
    • Since 1991, when USP published a dispensing standard to prevent accidental intrathecal injection of vincristine, no cases have been reported in the US to either FDA or USP
    • Transcription of order with incorrect spacing leads to an error.
    • Rhone-Poulenc Rorer's Taxotere® (docetaxel) was approved by FDA.
    • Warning! Prefilled unit-dose syringes of Pitocin4_, Benadryl®, and Dilantin® from Parke Davis look identical when removed from their shipping cartons.
    • FDA and ISMP are interested in learning more about medication errors with OTC products that use the same brand name despite different ingredients.

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