ISMP Medication Safety Alert! Acute Care Edition

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October 6, 2005

Unfortunately, this time it wasn't the equipment
Look- and sound-alike names.
Potential confusion may arise between fluoxetine and duloxetine.
Chemical burns.

Phenol burns a 3-year old child.
Cafcit label won’t change.

Despite confusion between CAFCIT (caffeine citrate) Oral Solution and Cafcit for injection, the company has informed ISMP that they will not be changing the packaging of these products.

Another risk of IV misconnections.

The V.A.C. Instill System accommodates IV tubing to deliver a topical solution and could lead to errors.
Filtered pump sets and Flolan (epoprostenol) interruption.

Mistakenly connecting the wrong end of the tubing of the administration set can prevent the delivery of epoprostenol because the tubing is designed to allow flow in one direction only.
Coumadin-Cardura mix-ups.
An order for CARDURA (doxazosin) is misinterpreted and dispensed as COUMADIN (warfarin).

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October 20, 2005

Preventing magnesium toxicity in obstetrics
New product labeling.
Novo Nordisk and FDA recently announced package labeling changes to two of their insulin products to help prevent mix-ups.

Prevent “death by decimal.”
New Duragesic-12 patch may help to prevent medication errors.

Warning label mix-ups.
A reader suggests separating similar warning labels to avoid mix-ups.

Quarterly Action Agenda: July – September 2005
ISMP has developed a selection of agenda items and actions to reduce the risk of medication errors at your practice site. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number (in parentheses) to locate additional information as desired. Continuing education credit will be available in the 3 to 4 weeks time for pharmacists and nurses.
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