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November 2, 2006

  • Promethazine conundrum: IV can hurt more than IM injection!
    Survey spurs interest in renewing efforts to prevent serious tissue damage
  • Low cost generics
  • Medication safety can be compromised if patients bypass their usual pharmacy to take advantage of retail pharmacy programs that provide a month’s supply of generic drugs for $ 4 or a similar nominal fee.

  • Drug selection error
  • A ziplock bag of medication should have contained diphenhydramine 50mg/mL, but actually contained a vial of heparin 10,000 units/mL. The drugs were stored two shelves apart and had similar packaging.

  • Out of darkness comes light
  • Nothing can erase the grief and loss experienced in the wake of the tragic heparin overdoses in Indiana that led to the death of three infants. But it should be of some comfort that some positive actions are occurring as a result of the tragedy.

  • What, not flatulence?
  • A verbal medication order was misheard as BEANO rather than B & O (belladonna and opium) suppositories.

Special Announcements

  • Publication

    The second edition of the ISMP book, Medication Errors (first published in 1999), edited by Michael R. Cohen, is now available. In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them. To place an order, please visit: www.ismp.org/products/medErrsEd2/default.asp.

  • Recognition
  • 9th Annual ISMP Cheers Awards. Please join us on December 5, 2006, at the Hilton Anaheim in CA, as we honor the 9th Annual ISMP Cheers Awards recipients. Charles R. Denham, MD, Chairman of Texas Medical Institute of Technology, will deliver the keynote address, and ISMP staff will present the Awards. For more information, please visit: www.ismp.org/Cheers/default.asp

  • Support
  • Medication safety program for rural hospitals. Small hospitals often face challenges managing safety priorities on limited resources and have difficulty finding educational programs that address their unique concerns. To help support those needs, ISMP is launching the ISMP Rural Hospital Medication Safety Connection. The Connection provides tools and collaborative learning opportunities to help rural hospitals significantly improve medication safety. For more information, please visit: www.ismp.org/Consult/ruralhospital/default.asp.

  • Education
  • ADC teleconference. Please join us for our next teleconference, Strategies for Safe Use of Automated Dispensing Cabinets (ADCs), on November 15, 2006, from 1:30 to 3:00 p.m. EST. This teleconference will identify the causes of errors related to ADCs and the components of a well-designed ADC system that can reduce the risk of errors. To register, visit: www.ismp.org/teleconferences/default.asp?teleconferenceID=21.

    Teleconference on package insert changes.ISMP and FDA will be holding a free teleconference, New Prescription Drug Information Format to Improve Patient Safety, on November 7, 2006, from 12:30 to 2 p.m. EST. FDA has revised the format of prescription drug information (package insert) to reduce the risk of errors and make the information more accessible for electronic use. To learn more, please contact: OSHI@fda.hhs.gov. Attendance is limited to 200 locations.


November 16, 2006

  • Pharmaceutical industry medical device companies:
    Part of the solution?
  • Since when is it a crime to be human?

    A nurse has been charged with criminal neglect in the medication error-related death of a 16-year-old woman during labor. This event reminds us of the importance to keep in mind there is much more to a medication error than what is presented in the media or criminal complaint.
  • Is it really saline?

    We recently learned about an unsafe practice with using prefilled saline flushes that poses very serious risks.
  • Dose counter may not work

    When the dosage counter of an
    ASMANEX TWISTHALER (mometasone furoate) reaches “00” and enough force is applied while twisting the inhaler cap, the dosage counter can fail and reset to “199”.

Special Announcements

  • Publication

    The second edition of the ISMP book, Medication Errors (first published in 1999), edited by Michael R. Cohen, is now available. In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them. To place an order, please visit: www.ismp.org/products/medErrsEd2/default.asp.

  • Recognition
  • 9th Annual ISMP Cheers Awards. Please join us on December 5, 2006, at the Hilton Anaheim in CA, as we honor the 9th Annual ISMP Cheers Awards recipients. Charles R. Denham, MD, Chairman of Texas Medical Institute of Technology, will deliver the keynote address, and ISMP staff will present the Awards. For more information, please visit: www.ismp.org/Cheers/default.asp

  • Support
  • Medication safety program for rural hospitals. Small hospitals often face challenges managing safety priorities on limited resources and have difficulty finding educational programs that address their unique concerns. To help support those needs, ISMP is launching the ISMP Rural Hospital Medication Safety Connection. The Connection provides tools and collaborative learning opportunities to help rural hospitals significantly improve medication safety. For more information, please visit: www.ismp.org/Consult/ruralhospital/default.asp.

  • Education
  • ADC teleconference. Please join us for our next teleconference, Strategies for Safe Use of Automated Dispensing Cabinets (ADCs), on November 15, 2006, from 1:30 to 3:00 p.m. EST. This teleconference will identify the causes of errors related to ADCs and the components of a well-designed ADC system that can reduce the risk of errors. To register, visit: www.ismp.org/teleconferences/default.asp?teleconferenceID=21.

    Teleconference on package insert changes. ISMP and FDA will be holding a free teleconference, New Prescription Drug Information Format to Improve Patient Safety, on November 7, 2006, from 12:30 to 2 p.m. EST. FDA has revised the format of prescription drug information (package insert) to reduce the risk of errors and make the information more accessible for electronic use. To learn more, please contact: OSHI@fda.hhs.gov. Attendance is limited to 200 locations.

November 30, 2006

  • PEN injectors: Technology is not without imPENding risks
  • Look-alike bags of sterile water and sodium chloride: Patients might turn blue, too!

    A respiratory therapy director recently contacted his distributor of sterile water for inhalation, Cardinal Health, to request a labeling change to reduce the risk of life threatening errors if it is confused with look-alike bags of saline.

  • Enjuvia or Januvia?
  • Although tablet strengths and clinical indications are dissimilar, it’s hard to miss how similar the names, ENJUVIA (synthetic conjugated estrogens, B) and JANUVIA (sitagliptin phosphate) sound.

  • Order entry error
  • Pharmacy robots can only dispense medications accurately if they are entered into an order entry system correctly. A pharmacist incorrectly entered in an order for 0.06 mg of oral digoxin as 0.625 mg daily for which a dispensing robot filled using 5 tablets of the 0.125 mg strength.

  • Caution with Zydis technology
  • ZELEPAR (selegiline) recently became available for use in ZYDIS technology. This formulation has the potential to be confused with ZYPREXA ZYDIS (olanzapine) when the medication is prescribed simply as “Zydis”.

  • News Update… More on WI nurse facing criminal charges
  • Additional information has surfaced about the medication error-related death of a 16-year-old Wisconsin woman during labor.

Special Announcements

  • ISMP Safe Medication Management Fellowship
  • ISMP’s Safe Medication Management Fellowship is a unique 12-month program beginning each July that educates a healthcare practitioner in error prevention and safe medication use methods. Information and application can be found at www.ismp.org/profdevelopment/managementfellowship.asp. All applications must be received by March 31, 2007.

  • Publication
  • The second edition of the ISMP book, Medication Errors (first published in 1999), edited by Michael R. Cohen, is now available. In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them. To place an order, please visit: www.ismp.org/products/medErrsEd2/default.asp.

  • Recognition
  • 9th Annual ISMP Cheers Awards. Please join us on December 5, 2006, at the Hilton Anaheim in CA, as we honor the 9th Annual ISMP Cheers Awards recipients. Charles R. Denham, MD, Chairman of Texas Medical Institute of Technology, will deliver the keynote address, and ISMP staff will present the Awards. For more information, please visit: www.ismp.org/Cheers/default.asp

  • Support

  • Medication safety program for rural hospitals. Small hospitals often face challenges managing safety priorities on limited resources and have difficulty finding educational programs that address their unique concerns. To help support those needs, ISMP is launching the ISMP Rural Hospital Medication Safety Connection. The Connection provides tools and collaborative learning opportunities to help rural hospitals significantly improve medication safety. For more information, please visit: www.ismp.org/Consult/ruralhospital/default.asp.

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