The following are excerpts from the newsletter
- Admitting "overflow"
patients to units without proper expertise is a setup for
- ISMP Action
Agenda: Items from the ISMP Medication Safety Alert!, July
- Sept, 2000
- Safety Briefs:
- InKine Pharmaceutical Company's bowel-cleansing drug
DIACOL (sodium phosphate) will now be marketed using
the brand name VISICOL.
- Textbook errata: In separate drug references, errors
have been made when listing the recommended dose for
AGGRASTAT (tirofiban). The first error appears in the
PDR Nurse Drug Handbook 2000, which lists the loading
dose of tirofiban as 0.4 mg/kg instead of 0.4 mcg/kg.
However, the maintenance dose is correctly listed as
0.1 mcg/kg/minute. A similar error appears in Saunders'
Nursing Drug Book 2001. This text lists the loading
dose of tirofiban as 0.4 mg/kg and the maintenance dose
as 0.1 mg/kg. Both errors were reported to the publishers
and steps are being taken to correct the information.
Also, in "Guidelines 2000 for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care" (Circulation 102;1-121),
the atropine dose for bradycardia is listed as 0.5 -
1 g IV. The correct dose, of course, is 0.5 - 1 mg IV.
However, the algorithms in the document list the correct
dose of atropine.
- PROTAIN XL" (Mead-Johnson Nutritionals), a high protein
tube-feeding product with fiber, could be confused with
"PROCARDIA XL" (nifedipine) if written poorly.
- FDA has sent a letter to AstraZeneca warning them
to stop promoting the idea that generic propofol is
less safe than DIPRIVAN.
- SmithKline Beecham will market Texas Biotechnology
Corporation's new anticoagulant drug under the generic
name, argatroban. Strong name recognition was cited
as one reason for FDA approval of using the generic
name without a trademark.
- The winners of our Medication Safety Contest have
been notified this week. The contest called for entries
in four medication safety categories: a job description
for a medication safety practitioner; a policy for a
non-punitive, system-based error reporting program;
a medication safety exam or program for new staff; and
a survey to solicit information about the culture of
Health Systems in Lubbock, TX, submitted the winning
entry for a medication safety nurse specialist job description.
Hospital in Frederick, MD, sent in the winning entry
for a non-punitive reporting program.
Allina Hospitals and Clinics in Minneapolis, MN, won
for their entry of a medication safety orientation program.
and Clinics also submitted the winning entry for a patient
safety culture assessment. We received such wonderful
entries in each category that we also selected two organizations
for "honorable mention": Raleigh
General Hospital in Beckley, WV, for submitting a practitioner
survey about error reporting; and Allina
Hospitals and Clinics for a patient safety project manager
job description. The winners will receive a monetary
award and a copy of the ISMP book, Medication Errors.
Thanks to all who participated!
- Two interesting conferences covering cutting edge
issues! On October 26-27, 2000, ECRI will present a
conference, in the Philadelphia area, "Beyond Medical
Error: How the healthcare community accepts new technology
as 'safe'." Visit www.ecri.org/taconf2000 for details.
On October 30-31, 2000, the Latiolais Leadership Program
will hold a forum in Scottsdale, AZ on "The Application
of Human Factors Engineering to Improve Medication Use
Safety." For further information, contact Philip Schneider
- There is much to
talk about during NCPIE's "Talk About Prescriptions Month!"
points for "Talk About Prescription Month"
- Safety Briefs:
- Searle Pharmaceutical sends letter about off label
use of CYTOTEC.
- CECON labeling does not indicate strength.
Picture of Cecon packaging
- Recent delay in flu vaccine availability points out
necessity for clear directions for administration.
- More problems with abbreviation "IU" reported. The
order below for Bicillin was interperted as IV (intravenous).
- Subscriber Feedback
- Welcome to our newest staff members! Marci Kropff,
Pharm.D., who completed the 1999-2000 ISMP fellowship,
is joining our staff as a medication safety specialist.
In August, Matthew Grissinger, RPh, began a one-year
Safe Medication Management Fellowship with ISMP. This
program is funded through grants from Becton Dickinson
(BD) and Medicis Pharmaceutical Company. Matt has extensive
experience in long term care, home care, and has served
as a JC surveyor. Susan Paparella, RN, BSN has joined
ISMP's risk management staff. Susan has twenty years
experience in critical care nursing, risk management
and quality improvement. Also, we welcome Lynne Morrison,
our new office manager