ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook
Site Search by PicoSearch. Help

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).

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.

subscribe now

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Survey Results
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officer Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP