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September 8, 2005

• Be aware of false glucose results with point-of-care testing
• Hidden information
  Look-alike packaging of ceftriaxone vials may lead to errors.
• TOPic for discussion
  A dispensing error involving a mix-up between TOPAMAX (topiramate) and TOPROL-XL (metoprolol) results in adverse consequences for a patient.
• Don’t let this “flu” get you
  A prescribing error involving fluvoxamine and fluoxetine is uncovered through medication reconciliation.
• Bigger is better
  Changes are made to improve the unit-dose package labels for RISPERDAL (risperidone) M-Tab tablets.
• Location, location, location
  Mayne Pharma makes changes to improve the labeling of their morphine sulfate product.

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September 22, 2005

• Paralyzed by mistakes: Preventing errors with neuromuscular blocking agents
• Hmmm.Think about this.
  Unintended consequences can occur from the misinterpretation of sliding scale insulin orders.
• Be prepared for interruptions when outsourcing services
  Central Admixture Pharmacy Service recalled some injectable products due to concerns regarding the sterility. Were you ready?
• Look- and sound-alike names
  Confusion between SALAGEN (pilocarpine) and selegiline leads to medication errors.
• Bigger is better
  Changes are made to improve the unit-dose package labels for RISPERDAL (risperidone) M-Tab tablets.
• ISMP errata
  Precision Xtra was incorrectly listed in the text of the September 8th 2005 newsletter as a brand that provided false glucose reading in patients receiving maltose or icodextrin products.
• ISMP Teleconference
  Our next teleconference will be October 27, 2005, on "Just Culture- an Emerging Safety-Centered Accountability Model".
  

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