The following are excerpts from the newsletter
- "Prescription mapping" can
improve efficiency while minimizing errors with look-alike
- ISMP Action Agenda: Items from the ISMP Medication Safety Alert!, July - Sept, 1999
- Safety Briefs:
- Caution: The FDA MEDWATCH
and USP-ISMP medication error databases contain over
30 reports about mix-ups between ZYRTEC (cetirizine),
an antihistamine, and ZYPREXA (olanzapine), an antipsychotic.
- An order for 0.75 mg SYNTHROID for a newly
admitted patient was checked with the family who thought
that the order "sounded right". The original prescription
container arrived later and the dose was actually for
0.075 mg. Order clarifications should be directed to
the prescriber not an intermediary.
- Patients treated with MIRAPEX (pramipexole),
a dopamine agonist indicated for the treatment of the
signs and symptoms of idiopathic Parkinson's disease,
have reported falling asleep while engaged in activities
of daily living, such as eating, during conversations,
and driving a car. Patients should be alerted and told
not to drive until they have used the drug for a sufficient
period of time to know how they will react.
- Gate Pharmaceuticals is informing health professionals
about the possibility of sudden death when ORAP
(pimozide) is given in high doses (greater than 10 mg).
- Maintaining patient safety
in the face of staff reduction
- Generic propofol: Safe substitute?
- Safety Briefs:
issues description of problem with procedure for reconstituting
- Drugs such as COUMADIN (warfarin) and SYNTHROID (levothyroxine)
are available in a wide range of dosages to accommodate
expected variation in patient specific doses. Some pharmacies
stock only some of the available strengths. Pharmacists
should take note of the drugs that require dispensing
multiple tablets in different strengths to accommodate
the typical dosage range and then, increase the variety
of strengths available to avoid confusion with drug
administration directions and minimize the possibility
- Consider subscribing to a few of the available "mailing
lists," which provide medication safety information
directly to you via email.
- DuPont Pharmaceuticals Company sent letters recently
to pharmacists and physicians about adverse events caused
by concomitant use of COUMADIN and a generic warfarin.
- A table in the current edition of The Pediatric Dosage
Handbook (6th Edition; Lexi-Comp) incorrectly lists
doses of IV midazolam (VERSED) in mg rather than mg/kg.
The table is on page 1284.