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The following are excerpts from the newsletter

September 10,1997

  • Hazard warning!
  • NCCMERP recommends medical product packaging and labeling simplification
  • IV benzodiazepine guidelines
  • Safety Briefs:
    • Many asthma paatients continue to use inhalers long after medicine may be gone.
    • Trivia -- MLT staands for multilayer tablet.
    • Patients may not let pharmacist know when a prescription is filled incorrectly. Work to cultivate them to help in the error prevention system.
    • Communication of dosing information for long term care patients admitted to the hospital requires coordination of patient information and drug information.
    • Institutions with specialty care units sometimes admit other types of patients to those units. This at times can cause confusion in the types of therapy really needed.
    • Two recent errors occurred due to misunderstood emergency verbal orders. Verbal orders must be clear...An order for half an amp of something is not clear when the dru;g is available in multiple strengths.
    • Zebeta®(an antihypertensive can be mistake for DiaBeta® an antidiabetic agent.

September 24, 1997

  • Preparing for a damaging medication error
  • Pharmacy board report reveals ADE patterns.
  • Safety Briefs:
    • Name Alert 1: Diovan® a new antihypertensive can look like Darvon®.
    • Name Alert 2: when written poorly Posicor® looks very similar to Proscar®.
    • Senate FDA Reform Bill (S 830) includes provisions for simplification of labeling.
    • Ortho-McNeil contacted about packaging of Levaquin®.
    • Accolate® advertisement shows prescription which includes the indication. This might trigger prescribers to include the indication on prescriptions, not only for Accolate, but for other medications as well.
    • Recall of Pondimin® and Redux® points up need for post marketing surveillance and need for more rapid communication of early events from FDA.
    • TAC and SPA --- Problematic abbreviations. Order for TAC 0.1% for triamcinolone was written by a resident. Pharmacist almost filled it with hospital's standard formula for tetracaine,adrenaline and cocaine solution. Avoid the abbreviations.....Avoid the mistakes.
    • Baxter's Mini-Bag Plus® System where vial is attached to an IV minibag and reconstituted immediately before use requires forcing liquid from minibag into vial and from vial into minibag. Some of the dose may not be forced back into the bag and administered

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