The following are excerpts from the newsletter
- Safe practice recommendations for
using vitamin K1 to reverse excessive warfarin anticoagulation
- Increased potential exists for misprogramming devices
that automatically calculate infusion rates
- Safety Briefs:
- With a severe shortage of penicillin G potassium or
has issued suggestions for alternatives. Use caution
with the administration of these alternatives.
- Glaxo Wellcome has voluntarily withdrawn RAXAR (grepafloxacin)
due to a small number of patients who experienced severe
cardiovascular events (torsade de pointes).
- Nitroglycerin transdermal patches, distributed by
Mylan Pharmaceuticals, are clear and blend in with skin
color so well that they are nearly invisible. As a result,
patch removal may be missed or forgotten.
- In our last issue we mentioned that a table in the
current (6th) edition of Lexi-Comp's The Pediatric
Dosage Handbook incorrectly lists doses of midazolam
(VERSED) in mg rather than mg/kg. However, we cited
the page number for the 5th edition (page 1284), which
also has the dose expressed erroneously. The table in
the 6th edition is on page 1070.
- NATRU-VENT, an OTC saline nasal spray manufactured
by Boehringer Ingelheim Consumer Healthcare Products,
has a name that looks and sounds like their prescription
inhaler, ATROVENT (ipratropium).
- Last week, mass media attention was focused on a case
in Odessa, TX, where a cardiologist was held liable
for a fatal medication error caused by poor handwriting.
- ISMP's Board of Trustees is delighted to be hosting
its second annual Cheers Awards Dinner, at the
ASHP meeting on Tuesday evening, December 7, 1999. Call
for more information.
similarities exist between infection control and medication
- Dosing cards for Aggrastat may lead to error
- Safety Briefs:
- Influenza Virus Vaccine labeling may cause confusion.
Top: Picture of Vaccine for patients
13 years and older
Bottom: Vaccine for patients 6 months and older
- FDA provides Y2K information regarding drug shortages
- Correction! Due to a misprint, the ISMP Quarterly
Action Agenda for July - September 1999 (published in
our October 6th issue) indicated that ferrous sulfate drops
contain "75 mg of elemental iron per 0.6 mL." Ferrous
sulfate drops contain 75 mg of ferrous sulfate, or 15
mg of elemental iron, per 0.6 mL. Please note the correction
on your Action Agenda.
- Bayer Corporation is relabeling the diluent for CIPRO
Oral Suspension to help prevent mistakes.
Picture of new Diluent label
- Last week, another error with Cipro was reported where
the nurse administered the entire 100 mL container of
Cipro (10 g/100 mL) instead of 5 mL (500 mg) as ordered,
despite pharmacy labeling of the dosage and volume to
- The Institute of Medicine is about to publish
report on error in medicine and what needs to happen
within health care organizations. Linda Kahn, Ph.D.,
co-director of the project will be keynote speaker at
- ISMP Exhibitors' Theaters at the ASHP Midyear Clinical
Mon. December 6, 1999.......Chemotherapy To Do List: Expert
Tues. December 7, 1999......Closing the Patient Safety Loop:
Applying Today's Technology Throughout the Drug Use