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The following are excerpts from the newsletter


September 6, 2000

  • Adverse drug reactions: Documentation is important but communication is critical
  • FDA Advise-ERR: Medication errors associated with levothyroxine products
  • U.S. medication error reporting programs
  • Safety Briefs:
    • Be alert for patients on TIKOSYN (dofetilide) and the drug interactions associated with its use.
    • The Joint Commission (JC) has issued draft revisions for field review of standards that support medical/healthcare error reduction programs in accredited organizations.
    • We thank the nearly 1,450 U.S. hospitals that submitted data to ISMP after participating in the Medication Safety Self-Assessment project that ended on August 31, 2000. Analysis will begin shortly and a report will be sent to all participating hospitals by the end of the year.
    • Theoretical warning about confusion of ZEBETA and DIABETA becomes reality

September 20, 2000

  • Acute myocardial infarction therapy: there's simply no room for error
  • Chicago Tribune series misrepresents medical error
  • Safety Briefs:
    • Important: We published a special hazard alert last week about dangerously similar packaging and labeling of pancuronium and enalaprilat injection distributed by Baxter Pharmaceutical Products Inc. The alert, which includes a color photograph of the vials, appears on our web site home page ( Since a fatality might occur if pancuronium is given accidentally to a patient who is not mechanically ventilated, for now we recommend purchasing one of these products from a different company. Baxter is aware of the problem and is taking appropriate action.
    • Levothyroxine errors can occur when switching levothyroxine from the oral to the IV route without halving the dose.
    • Serious malaria outbreak tied to misuse of multiple dose vials.
    • We will be contacting the four winners of the ISMP Medication Safety Contest next week to award the $250 cash prizes.
    • We're accepting nominations for the 2000 ISMP Cheers Awards to honor a subscriber organization that has proactively used this publication to improve medication safety.
    • The federal Quality Interagency Coordination Task Force held a national summit on Monday, September 11, 2000, in Washington, D.C. to help set a research agenda on medical errors and patient safety.
    • Report of cellular phone causing pump malfunction

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