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The following are excerpts from the newsletter

October 7, 1998

  • A caution about NARCAN - NORCURON confusion.
  • ISMP Action Agenda: Items from the ISMP Medication Safety Alert!, July - Sept, 1998
  • Safety Briefs:
    • PLEASE: WE NEED YOUR HELP! We have repeatedly written about accidents involving misinterpretation of the total amount of drug in CEREBYX (fosphenytoin) and KETALAR (ketamine) vials. Cerebyx and Ketalar labels (and generic ketamine labels) express the drug name and concentration in a bright color, which makes the per mL amount stand out from other label information, including the total volume of the vial.
    • We are looking forward to Upjohn Depo-Medrol being repackaged as a Pharmacia and Upjohn product! Cartons containing 1 and 5 mL vials appear identical, but on close examination, one can see that the 1 mL vial is a single use vial and the 5 mL vial contains benzyl alcohol as a preservative.

      Image of Upjohn's Depo-Medrol packaging
    • A hospital pharmacist has reported four cases where nurses failed to activate dual-chambered bags of amino acid/dextrose solutions (known as Quick-Mix(Dual Chamber Container) distributed by Clintec Nutrition (Abbott manufactures similar combinations in Nutramix dual chamber containers). Until activated by the user, a seal separates a lower chamber of 500 mL of 5.5% TRAVASOL (amino acid) from 500 mL of 10% dextrose injection. In each case the patient received 5.5% instead of 2.75% amino acid.

October 21, 1998

  • Atrovent Inhalation Aerosol and peanut allergy
  • Survey shows subscribers using information, but Safety Alert! needs wider distribution.
  • Safety Briefs:
    • Strange bedfellows: Isn't it ironic that on some community pharmacy shelves you will find OTC ZANTAC (ranitidine) 75 mg tablets packaged with a free trial size of EXCEDRIN (aspirin, acetaminophen and caffeine) tablets? Since the adverse effects of aspirin are primarily gastrointestinal, such as blood loss, gastritis, and esophagitis, shouldn't it be free Zantac with the Excedrin?

      Excedrin & Zantac in one shrinkwrap package
    • For many years Muro has provided PRELONE Syrup (prednisolone) in a 15 mg/5 mL concentration. Now they've introduced a 5 mg/5 mL strength. Watch dosing carefully to avoid mistakes.
    • Pfizer and Searle announced last week that celecoxib, presently an investigational COX-2 inhibitor for arthritis, will be renamed to hopefully avoid confusion with other similarly named products.
    • Twice in the same hospital, gentian violet solution (for external use only, avoid eye contact) was instilled into a patient's eyes instead of gentamicin ophthalmic solution.
    • We thank all who responded to our request last week for information about CEREBYX (fosphenytoin) medication errors. We learned about a number of previously unknown 10-fold overdoses related to the way the drug's concentration is expressed on the label. Sadly, the errors included a death

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