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September 10, 2009
- How has the current economy affected patient safety?
- Quinine-quinidine mix-ups still happen
Check out the newsletter to learn about an error that occurred as a result of a mix-up between quinNINE and quiNIDine and how you can prevent similar errors from occurring in your healthcare organization.
- Printing an outpatient prescription from an inpatient pharmacy computer list? Be sure all relevant information is included!
Certain computerized prescriber order entry (CPOE) systems allow generation of outpatient prescriptions by utilizing inpatient orders. An error occurred, however, when generating a prescription from an inpatient order for a product that was specially compounded at the hospital. You can find more about this error and what important piece of information was excluded from the outpatient prescription in this issue of the newsletter.
- In the News…Criminal penalties for not reporting!
The state of Ohio has introduced new legislation which would require pharmacists, pharmacy interns, and qualified pharmacy technicians to report suspected dispensing errors with “dangerous drugs.” Failure to report to the Board of Pharmacy could result in criminal penalties. To express your opinion regarding this pending legislation please contact Senator Grendell and members of the Senate’s Health, Human Services, and Aging Committee (www.senate.state.oh.us/committees/com_health.html).
- Safety Brief: Unscannable barcode.
The Veterans Health Administration Office of Health Information Bar Code Resource has alerted us to an issue regarding scannability of DIANEAL Low Calcium Peritoneal Dialysis Solution. Check out the newsletter to find out if this is a product you utilize at your facility and how this scanning issue may affect your organization.
- Safety Brief: Increase the uptake.
ISMP would like to congratulate Therese Staublin, PharmD, from the Sisters of St. Frances Health System in Indiana, for distributing the ISMP Medication Safety Alert! in a relevant manner to others at her facility. Find ideas for how to provide our newsletter in a more significant manner to healthcare providers at your hospital in this issue of the newsletter.
- ISMP’s Medication Safety Intensive: October 8-9, 2009, Scottsdale, AZ. This unique 2-day workshop will help you look at your organization “through the eyes of ISMP” medication safety experts, who will take you through their real-world experiences in establishing and evaluating medication safety programs. For details, visit: www.ismp.org/educational/MSI/default.asp.
- ISMP October teleconferences.
October 6: Beyond the 5 Rights: A Safety Bolus for Nursing Leadership. Learn where risk is present but “hidden” in your medication administration system, and discover the high-leverage error-reduction strategies that can reduce the risk of harmful errors. Speakers will also discuss common at-risk behaviors that lead to errors during medication administration and the nurse leader’s role in establishing a learning culture.
October 15: Preventing Errors with Insulin: A Multidisciplinary Approach. We will explore the current trends in insulin therapy, barriers to optimal therapy and safety, and common errors that occur with insulin. Error prevention strategies will be presented, including improved communication of insulin orders as well as safe preparation, storage, delivery, and administration of insulin, including the use of insulin pens. For details on both programs, please visit: www.ismp.org/educational/teleconferences.asp.
- ISMP Survey: What’s a near miss? Thanks to more than 3,500 respondents who answered our survey on the definition of a near miss. We will provide the results in our next newsletter.
- ISMP Survey: Impact of Economic Crisis on Medication Safety. We are interested in learning how today’s economy is affecting patient safety at your healthcare organization. Please take a few minutes to take our survey and submit your responses to ISMP by October 16, 2009, at www.ismp.org/survey/survey200909.asp or by fax (215-914-1492) if you don’t have access to the Internet.
- Free Safety Videos. The latest medication related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp). Check them out!
September 24, 2009
- ISMP survey helps define near miss and close call
- What does a bar-coding scanner beep mean?
What does the audio alert or “beep” issued by your hospital’s point-of-care bar-coding system during the scanning process indicate? Check out the newsletter to read about the potential for misunderstanding that could occur with these audio tones and steps that you should take to determine if this is an issue that exists at your facility.
- APSF offers recommendations for safe post-op opioid administration and monitoring
The Anesthesia Patient Safety Foundation (APSF) recently published an editorial about the continuing problem of opioid-induced respiratory depression. You can find a summary of APSF’s observations and recommendations in this issue of the newsletter.
- Safety Brief: Promethazine IV update.
FDA announced last week that it’s requiring stronger manufacturer warnings about severe tissue damage related to accidental intraarterial administration or extravasation of IV promethazine. Read more about the required boxed warning and label revisions in our newsletter.
- Safety Brief: Potency of USP heparin unit changing.
In response to the 2007 and 2008 heparin crisis, USP has adopted a new potency assay and reference standard in order to secure the supply of safe heparin products. More detail about these safeguards and what, if any, implications they may have on clinical practice are provided in this issue of the newsletter.
- Safety Brief: Caution regarding once weekly levothyroxine.
A recent article in the journal Hospital Pharmacy suggests that once-weekly administration of levothyroxine may be as effective as daily dosing; however, ISMP is concerned that this new dosing regimen may lead to medication errors. Find out what safety concern ISMP has regarding once-weekly levothyroxine in this issue of the newsletter.
- Safety Brief: ConsumerMedSafety.org news.
Our consumer website has been honored with a Best of Show award in the nonprofit category at the Web Marketing Association’s WebAward show. Check out our consumer website at: www.consumermedsafety.org to view all of the available safety articles, tools, and alerts.