The following are excerpts from the newsletter
- Putting the cart before the horse: Will expanded clinical
services be safe?
- Ironing out a problem: Measuring
pediatric iron products safely
- Safety Briefs
- Searle & Pfizer send letter to 50,000 pharmacies advising
them that CELEBREX (celecoxib), CELEXA (citalopram)
and CEREBYX (fosphenytoin) may look or sound alike and
that the name (brand and generic), dosage form and strength
should be checked before dispensing one of these drugs.
- Excessive dose of cisplatin causes hearing loss and
acute renal failure in patient when an order is typed
leaving out the space between the "l" in cisplatinol
and the dose.
- Another error due to mistyping an order... When a
"F" was struck rather than the "G". The
directions appeared as Five ¼ teaspoonful
instead of Give ¼ teaspoonful.
- Confusion when converting the micrograms to the volume
needed for a dose of fentanyl resulted in error and
- Caution! BENTYL (dicyclomine) ampuls (Merrell Pharmaceuticals)
are labeled 10 mg/mL but the 2 mL total volume (20 mg
) is not listed.
- Medication error prevention text available. In June,
the American Pharmaceutical Association (APhA) will
publish the book, Medication Errors.
May 19, 1999
- Voluntary error reporting
is best public policy
- Medication listings in discharge summaries often provide
an inaccurate medication history.
- Safety Briefs
- Recent newspaper articles from different cities citing
two separate instances where prescriptions for chlorpromazine
were accidentally filled with chlorpropamide.
- FDA is warning about new safety concerns with ENBREL
- On the lighter side! An order was written for "NO
SLO-BID." Although the order was intended to discontinue
the drug, SLO-BID (theophylline). Later, a nurse called
the pharmacy to request a dose of "NOSLO," which she
thought was ordered BID!
- Prescription for PROFEN II mistaken for PROFEN. PROFEN
II is actually phenylpropanolamine/guaifenesin.
- We've moved! Please note our new address: 200 Lakeside Drive, Suite 200, Horsham, PA 19044.
Phone 215 947 7797 Fax 215 914 1492