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The following are excerpts from the newsletter

September 4, 2002

  • Involving non-clinical departments in patient safety discussions can reduce the risk of serious errors
  • Verbal order spells near disaster - A premature baby girl developed respiratory problems shortly after birth. Plans were made to transfer her to a NICU at a nearby children's hospital. While awaiting transfer, the physician gave a verbal order to administer ampicillin 200 mg and gentamicin 5 mg IV push. The nurse misheard the second antibiotic order as gentamicin 500 mg.
  • Safety Briefs
    • A patient received what was supposed to be 80 units of Lantus insulin at bedtime. But when the night nurse went to check on her shortly after the start of the shift, the woman was unresponsive and her blood glucose was just 17 mg/dL. A quick investigation identified that the patient had received the bedtime dose of insulin using Humalog, not Lantus.
    • A pharmacy received a new prescription for compounded nitroglycerin 0.2% ointment, which is used topically for rectal fissures. The prescription was filled properly, but the NDC (National Drug Code) number for the 2% ointment used to compound the product was entered into the computer. When the prescription was refilled one month later, another pharmacist filled the prescription with nitroglycerin 2% ointment instead of 0.2%.
    • Caution: Don't confuse LUPRON DEPOT-PED (leuprolide acetate) with LUPRON DEPOT-3 MONTH. Recently we heard about an error involving multiple pediatric patients who had outpatient prescription orders for the pediatric dosage form.


    • Join us in welcoming Thomas J. Moore as Senior Scientist, Drug Safety and Policy, at ISMP. Tom has spent more than a decade as a researcher, writer and lecturer on the risks and benefits of prescription drugs. Also, join us in welcoming Christopher S. Walsh, PharmD, the 2002-2003 ISMP Scholar-in-Residence.
    • A community/ambulatory care edition of ISMP Medication Safety Alert! is being launched this month. Information from our current newsletter that has relevance to ambulatory care, as well as other material for practitioners outside of the acute care environment, will be included. The newsletter is available electronically in a newly designed format as an Adobe Acrobat PDF file.
    • ISMP's Med-ERRS subsidiary has announced it will be presenting an important educational seminar designed to update pharmaceutical industry executives involved in legal, marketing and regulatory affairs on the latest developments in medication safety. Minimizing Pharmaceutical Trademark, Packaging and Labeling Risks will be held at the Conference Center at the New Jersey Hospital Association on Friday, November 1, 2002 in Princeton, NJ.
    • Nominations invited for ISMP Cheers Awards - Once again, it's time to hear from you about an individual, hospital, health system, or a company you believe has done something extraordinary in the area of medication safety during the past year. ISMP recognizes outstanding contributions to medication safety at our annual Cheers Awards banquet during the ASHP Midyear Clinical Meeting. We are also now accepting nominations for the 2002 ISMP Medication Safety Alert! Subscriber Award, which honors an organization that has proactively used this publication to improve medication safety. This year's dinner is on Tuesday evening, December 10, 2002, in Atlanta. Cheers Awardees and Subscriber Awardees receive national recognition for their outstanding work, a beautiful crystal figurine, and a travel stipend to attend the dinner. This year's Lifetime Achievement Award recipient is Kenneth N. Barker, Ph.D. Professor and Head of the Department of Pharmacy Care Systems Auburn University School of Pharmacy, Auburn, AL.

September 18, 2002

  • Bad "marks" for order communication
  • "Maximize" safety when titrating drug doses - Accepting orders for titration of medications without dose limits is unsafe. For example, an order was written for "LEVOPHED (norepinephrine) drip, start at 1 mcg/min and titrate to systolic BP greater than 90". An ICU nurse titrated a dose of norepinephrine up to 38 mcg/minute to maintain a systolic blood pressure greater than 90 mmHg.
  • Safety Briefs
    • Once again, we must caution against look-alike confusion between generic tramadol hydrochloride 50 mg and trazodone hydrochloride 50 mg. Recently an actual error was reported from a community pharmacy using the Purepac brand.
    • A physician ordered MYLOTARG (gemtuzumab ozogamicin) 17 mg for a patient. This drug, available as a 5 mg vial, had to be ordered. When the medication came in, it was entered into the computer system using the invoice information, which listed the product as "Mylotarg 5 mg - 20 mL vial." But the 20 mL vial refers to the size of the container, not the volume after its reconstituted.
    • The American Society of Consultant Pharmacists (ASCP) has issued a position statement strongly opposing policies that deny payment for lower strengths of tablet dosage forms, or otherwise mandate tablet splitting by patients. The full statement, "what can go wrong" scenarios, and considerations for pharmacists who are called upon to dispense split tablets can be found at www.ascp.com/public/pr/policy/tabletsplitting/ .
    • Last week, the Advisory Committee on Regulatory Reform (established by Tommy Thompson, Secretary of Health and Human Services) voted unanimously that determination of drug name safety should, in most cases, be based on data supplied to FDA from sponsors.

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