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The following are excerpts from the newsletter

November 1, 2000

  • Orders to "continue previous meds" continue a longstanding problem
  • FDA Advise-ERR: Dispensing errors associated with Zantac and Zyrtec
  • Legislative update
  • David P. Vogel
    Our esteemed colleague, trustee, and friend, David P. Vogel, died on Sunday, October 22, 2000, from complications of gastric cancer. David was an extraordinary leader who freely contributed his time and energy to ISMP in support of its mission. David was assistant vice president of Robert Wood Johnson University Hospital in New Brunswick, NJ, as well as associate professor of pharmacy practice and administration at Rutgers University School of Pharmacy in Piscataway. His family, friends, students, and colleagues will miss him dearly. Donations in David's name can be sent to: David P. Vogel Pharmacy Education Memorial Fund, c/o Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901.
  • Safety Briefs:
    • Voice messaging and telephone answering devices present problems with interpertation of prescriptions
    • American College of Obstetricians and Gynecologists issues a news release to reaffirm its guidelines supporting use of the CYTOTEC (misoprostol) for induction of labor.
    • TEMODAR (temozolomide) labeling may lead to confusion.
    • ISMP's Board of Trustees is delighted to be hosting its third annual Cheers Awards Dinner, at the ASHP meeting on Tuesday evening, December 5, 2000. Call for more information.

November 15, 2000

  • ISMP survey shows weaknesses persist in hospital systems for error detection, reporting and analysis
  • FDA Advise-ERR: Medication errors associated with confusion between Flomax and Volmax
  • Safety Briefs:
    • Leapfrog Group announces its Purchasing Principles and Safety Standards and the results of an independent analysis conducted by Dartmouth Medical School.
    • Reports are beginning to trickle in about the potential for confusion between products that utilize the new ZYDIS technology.
    • An order written for morphine ".5 mg" instead of "0.5 mg" was misread by a pharmacist as 5 mg. The drug was dispensed for a newborn who later died from the overdose
    • The Learning Channel plans to air a four-part mini series, "Why Doctors Make Mistakes," on November 20 and 21, 2000. Running from 9 to 10 p.m. and 10 to 11 p.m. EST each night, the series will examine human error incidence in health care and how it can help or hinder future patient safety improvement efforts.
    • ISMP's Board of Trustees is delighted to be hosting its third annual Cheers Awards Dinner during the ASHP meeting on Tuesday evening, December 5, 2000. Join us at the Hilton Hotel in Las Vegas, NV, as we honor selected organizations and individuals that have made significant contributions to medication safety during the year. We would also like to thank the dinner sponsors to date. Companies include McKesson HBOC Automated Health Care, JPC Foundation, Baxa Corporation, Bridge Medical, Hoffman-La Roche, Autros Hospital Solutions, and The Liposome Company. Please call us at 215-947-7797 if you would like to attend the banquet and have not received an invitation. Special discount tickets are available for newsletter subscribers who are purchasing tickets independently. Corporate sponsors and their guests are welcome. Please show your support of ISMP activities through a corporate gift to ISMP or through sponsorship of tables for honorees and ASHP members and guests. Tickets are $125 for individuals and tables of 10 may be reserved for $1250. All proceeds are used to support ISMP medication safety activities. As a charitable organization, donations to ISMP are fully tax deductible. Please call for additional details.

November 29, 2000

  • In medicine, be wary of "misspeakers" who "shoot from the hip"
  • Presidential lessons: Problems with Florida election results can teach us much
  • Safety Briefs:
    • Containers of sodium chloride injection concentrate (23.4%) and MULTILYTE-20 (multi-electrolyte concentrate injection), both from American Pharmaceutical Partners, have black and red printing on a light blue background. If both products are available in a pharmacy's IV admixture area, there is a danger of a mix-up.

      SodiumChloride & Multilyte-20 image
    • Packaging changes for ACIPHEX (rabeprazole sodium), and ARICEPT (donepezil HCl), lead to near miss.

    • Patients with poor eyesight need your help to prevent dangerous medication errors.
    • Warning: a recent back order of gentamicin 40 mg/mL, 2 mL vials, has led many hospital pharmacies that lack total IV admixture programs to dispense the 20 mL multi-dose vial of gentamicin (40mg/mL) in unit dose carts.
    • There is a strong potential for sound-alike confusion between the proton pump inhibitor PROTONIX (pantoprazole sodium), and LOTRONEX (alosetron HCl), which is approved for use in irritable bowel syndrome in women.
  • Announcements
    • Congratulations to Rahway Hospital in Rahway, NJ, this year's ISMP Cheers Subscriber Award recipient. Rahway provided strong evidence of their commitment to medication safety by demonstrating a variety of multidisciplinary initiatives. The hospital actively incorporates information from the ISMP Medication Safety Alert! into practice decisions and system enhancements, and communicates changes to professional staff at all levels. Also, efforts to report and analyze "near misses" have become an important initiative to improve medication safety at the hospital. Rahway was chosen from a long list of other excellent hospitals that submitted nominations. The award will be presented during the ISMP Cheers Awards Dinner on December 5 at the Hilton during the ASHP Midyear Clinical Meeting in Las Vegas.
    • Once again we'd like to thank the approximately 1,500 hospitals that have responded on our web site, by fax, or by mail to the ISMP Medication Safety Self-Assessment. We are currently compiling the data and plan to mail aggregate comparisons to all hospitals that have sent data to ISMP. These comparisons will include total average scores and scores as a percentage of the maximum for each of the twenty core characteristics according to certain demographic information (e.g., bed size, rural/urban, teaching/non-teaching, and area of the country). We will also be supplying the maximum weighted score for each of the 194 representative self-assessment characteristics. Our timeline for this mailing will be the first week of January 2001. In the meantime we encourage hospitals that have completed the assessment to establish goals with their interdisciplinary team utilizing the answers from their assessment. For example, discuss all "A" responses, begin implementation of "B" responses, and enhance the full implementation of "C" and "D" responses. Your teams could set priorities for individual goals according to achievable results within the next 6 to 9 months, the next 9 to 18 months, and so forth. ISMP, in cooperation with the American Hospital Association, will provide a complete analysis of the results later in the year.

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