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The following are excerpts from the newsletter


November 5, 1997

  • Beta Block this order..
  • Missing the point.
  • Safety Briefs:
    • FDA issues a talk paper about changes in Rezulin® labeling.
    • Potential Mix up 1 --- Volmax® and Flomax®.
    • Potential Mix up 2 --- Serzone® and Seroquel®.
    • ICN pharmaceutical's vials of Prostigmin® look similar to its Tensilon® vials.
    • Potential for confusing prefilled syringes of Versed® with Valium® prefilled syringes.
    • .Thanks to those who have cotributed to ISMP through the United Way campaign.
    • Are you certain that proper techniques are being used by staff conducting mass influenza vaccination programs?
    • Study encourages patients to ask if the health care professional who comes in contact with them has washed his/her hands.
    • Standarization and control of vocabulary can help to reduce errors. Let ISMP and USP know about advertisements that use problem abbreviations by sending reports to the USP MERP.

November 19, 1997

  • When an error is not really an error
  • Removing discontinued medications.
  • Safety Briefs:
    • FDA announces intentions to require warning labels about alcohol consumption with over-the-counter pain relievers.
    • HHS Department issues preliminary recommendations for the management of patients that took fenfluramine or dexfenfluramine.
    • Lipid delivery systems for amphotericin B provide opportunity for dosage mixups.
    • QD (daily) abbreviation continues to cause problems ... it is often misinterperted as QID (four times a day).
    • Hospital in the news when a nurse almost makes a mistake. Patient's mother noticed that the syringe looked larger and stopps nurse who discovers miscalculation.
    • Systemic absorption of topical anesthetics is often forgotten, which in some cases can lead to disaatrous consequences.
    • A managed healthcare plan now covers Pepcid AC (OTC) and requires patients on prescription strength doses to use the OTC tablets to get the correct dose in order to cut costs. Thus a patient on 40 mg now takes 4 tablets instead of one

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