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The following are excerpts from the newsletter

April 5, 2012

  • QuarterWatch (second quarter 2011)
    Signals identified for fingolimod and inFLIXimab
  • Oncology self assessment.
    The Institute for Safe Medication Practices (ISMP), along with ISMP Canada and the International Society of Oncology Pharmacy Practitioners, has launched the 2012 ISMP International Medication Safety Self Assessment for Oncology.  Hospitals, ambulatory cancer centers, and physician office practices where chemotherapy is administered are being asked to convene interdisciplinary teams to complete the assessment tool. You can access the tool on the websites of all three organizations (
    www.ismpcanada). Data can be submitted online, anonymously, through June29, 2012. At the completion of the project, respondents will be able to compare their confidential results with aggregate results from demographically similar organizations and use the information to improve safety.
  • Safety BriefIt happened again.  Sadly, just last week, we learned that a large health system an error—EPINEPHrine was mistaken as lidocaine with EPINEPHrine. In discussing the repetition of this tragic error with ISMP staff and other patient safety experts, the human element is often mentioned in that people often do not fully appreciate the risk, or they believe the chance of an error is infinitesimally small. You can find a full description of this error and recommendations for how to prevent it from those who lived through it at: www.ismp.org/newsletters/acutecare/articles/19961204.asp. Beyond Blame is available at: http://onlinestore.ismp.org/shop/item.aspx?itemid=106.
  • Updated high-alert medication list. ISMP’s List of High-Alert Medications has been updated and can now be found on our website at: www.ismp.org/Tools/highAlertMedications.asp.
    One new drug was added to the list: vasopressin. Dexmedetomidine (PRECEDEX) was added as an example within the existing category of moderate sedation agents. Dabigatran (PRADAXA) was also added as an example within the existing class of antithrombotic agents. Colchicine injection was removed from the list since it is no longer available in the US. An interdisciplinary team of practitioners should use the newly updated List of High-Alert Medications to assess whether any drugs should be added or removed from their hospital’s list of high-alert medications.
  • FDA-ISMP partnership announced. As a part of its ongoing efforts to prevent medication errors and other risks, FDA’s Center for Drug Evaluation and Research has entered into an agreement with ISMP to develop collaborative efforts to reduce preventable harm from medicines, and to more effectively reach consumers with information on how to use medicines safely. More about the partnership can be found at: www.fda.gov/ForConsumers/ConsumerUpdates/ucm297644.htm.
  • ISMP webinars.  Join us on April 24 for a technology-focused webinar, Protecting Your Patients: Using an Active Surveillance System to Improve Quality and Safety of Medication Use.
  • Join us on May 22 to hear firsthand about the release of ISMP’s guidelines for safe preparation of IV admixtures. This very special webinar, Safe IV Compounding Procedures: The Release of ISMP Guidelines, will highlight best practice guidelines that were developed in response to a series of admixture tragedies involving IV compounding procedures. These guidelines are the result of an interdisciplinary safety summit held to perform an in-depth analysis of current compounding processes. For details on both webinars, visit: www.ismp.org/educational/webinars.asp.

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