August 26, 2010

• Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error
• Safety Brief: Odor neutralizer won’t protect skin
  
  A concern has been identified about a potential for mix-ups between a spray barrier film and a commonly used odor neutralizer. The two products are commonly used in hospitals and long-term care facilities and could potentially be in a patient’s room at the same time. Both products are available in similar size spray bottles and, therefore, look and appear very similar, although product label colors are slightly different. Check out this week’s issue to find out about which products were involved in the mix-up.
• Safety Brief: Look-alike vials
  
  An OR pharmacist reported to ISMP a potential for a mix-up between two injections that are commonly stored together in the OR medication cart. Find out more about the similarity between these two products.
• Safety Brief: Update to Hospira Symbiq recall
  
  Hospira has confirmed the root cause of the Symbiq infusion pump’s failure to detect air in the line (ISMP Medication Safety Alert! Safety briefs. May 6, 2010). Hospira will be replacing its microbore administration sets. In the meantime, the company issued an advisory recommending what current users can do to prevent this problem.
• Safety Brief: Sanofi aventis letter
  
  At the request of sanofi aventis, and as a public service, ISMP has agreed to provide a link to a letter from them regarding recent reports of label adherence issues with LOVENOX (enoxaparin) 30 mg and 40 mg prefilled unit dose syringes. The letter provides additional information about avoiding needlesticks when using the syringe and can be accessed through our newsletter.
• Null sign misread
  
  In prior issues of our newsletters, we discussed the possible misidentification of alphanumeric symbols in handwritten and computer-generated information. A nurse who read this recommendation in the June issue of Nurse Advise-ERR told us about a medication error that happened in her hospital that was caused in large part by a misinterpreted null sign. To learn more about this incident and to view ISMP’s recommendations, check out our current issue of the newsletter.
• Your reports at work
  

  Improved warnings coming for Clear Care
  Ciba Vision, the company that makes Clear Care Cleaning and Disinfecting Solution for contact lenses, informed us this week that they have been in communication with FDA regarding updates to the container warning system for their product. Our June 3, 2010, issue mentioned hundreds of incidents where contact lens wearers used the product improperly after missing warnings about soaking their lenses only in the special Clear Care contact lens holder packaged with the product. The company told us that they have been working on a new package design that would require the attachment of the contact lens holder to the bottle in order to use the solution. We hope that such a package will be available in the near future.

Special announcements

• ISMP webinar. Join us on September 28 for our next webinar, Beyond ‘Be Careful’: Maximizing Perinatal Medication Safety, which will focus on reducing risks in OB and ED settings. For information, visit: www.ismp.org/educational/webinars.asp.    

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