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The following are excerpts from the newsletter

April 19, 2012

  • A shortage of everything except errors: Harm associated with drug shortages

  • IV acetaminophen and overdoses in kids. In the February 2012 issue of Pediatrics, there is a warning from the Rocky Mountain Poison and Drug Center about the possibility of overdose errors with IV acetaminophen in infants and children. The IV form of acetaminophen was introduced in the US last year under the brand name OFIRMEV, which is approved for children 2 years and older. It is not approved for infants and toddlers under the age of 2, as it is in other countries, but unapproved off-label use in this age group is a possibility. The main problem has been 10-fold dosing errors. Each mL contains 10 mg of acetaminophen. Doses are calculated in mg, but when converting the mg dose to an amount for infusion, some health professionals have inadvertently confused mL and mg, which has led to 10-fold overdoses. The US product label mentions only mg dosing; infusion rates are not expressed in mL. In practice, we believe it would be much safer if BOTH the mg and mL doses were used when prescribing and communicating dosing information.

  • Safety Brief: ON-Q pump has Luer connector. The ON-Q PainBuster Post-Op Pain Relief System (I-Flow Corporation) incorporates tubing that attaches to infusion equipment with a Luer connector—common to IV lines. With bupivacaine and other local anesthetics employed in the device, the harm from bupivacaine induced cardiac toxicity with inadvertent attachment to an IV line seems obvious. No actual error has been reported to ISMP, but the pharmacist who related the incident to ISMP correctly points out that IV bupivacaine could be fatal if such an error occurred.

  • Safety Brief: Sodium bicarbonate shortage. Due to the current national shortage of sodium bicarbonate injection, many hospitals are reserving remaining supplies of this drug for use only during advanced cardiac life support or management of severe metabolic acidosis. Since the injectable form is also used to alkalinize the urine to increase excretion of methotrexate in high-dose therapy (www.ismp.org/sc?id=63), a pharmacist at a large cancer center told us that sodium acetate injection by infusion (it must be diluted if given IV) is being employed for this purpose during the shortage.

  • Safety Brief: Got Drugs? The Drug Enforcement Administration, working with state and local law enforcement agencies, is sponsoring National Prescription Drug Take Back Day (www.deadiversion.usdoj.gov) throughout the US. The next event is on Saturday, April 28, 2012, from 10:00 a.m. to 2:00 p.m. The event provides a venue for people to dispose of unwanted and unused prescription drugs at cooperating police stations.

  • Safety Brief: IV fat emulsion alternatives. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) has published a position paper, Clinical Role for Alternative Intravenous Fat Emulsions, in the April issue of Nutrition in Clinical Practice. Discussed are alternative oil-based fat emulsions, such as medium chain triglycerides (MCTs), olive oils (OOs), and fish oils (FOs). Based on extensive usage in Europe, these fat emulsions have an equivalent safety profile to soybean oil-based fat emulsions.

Special Announcements:

  • ISMP’s IV Compounding Summit Proceedings Available for Comment

    In October 2011, nearly 60 participants attended ISMP’s national invitational Sterile Preparation Compounding Safety Summit to address frequent and numerous reports of critical intravenous (IV) compounding errors. The draft of the IV summit proceedings is now available for public comment. We hope medication safety officers, hospital pharmacists, and other health professionals who rely on IV compounding services will take the time to review these proceedings and recommend changes, additions, or deletions as necessary. The comment period will be open until June 30, 2012. To review the proceedings and provide comments, please visit: www.ismp.org/tools/guidelines/IVSummit/.

  • 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. Using real examples, guest speakers will share how data from surveillance systems can help to safely manage medication therapy based on fluctuating patient-specific lab parameters, core measures, drug shortages, therapeutic drug monitoring, and antibiotic surveillance.

    •  Join us on May 22 to hear firsthand about the release of ISMP’s guidelines for safe preparation of IV admixtures. This 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

  • Medication Safety INTENSIVE

    Attend ISMP’s Medication Safety INTENSIVE workshop, a one-of-a-kind, interactive program that will teach you how to approach medication safety “through the eyes of ISMP.” Sharpen your risk assessment and event investigation skills, and learn more about human errors, Just Culture, Lean Six Sigma, high-leverage error-reduction strategies, and more. The next workshop will be held in Boston on June 21 and 22. For details, visit: www.ismp.org/educational/MSI.

  • ISMP Congratulates Kelly Besco

    ISMP congratulates former ISMP Safe Medication Management Fellow, Kelly Besco, PharmD, FISMP, who was recently recognized by the Ohio Society of Health-System Pharmacists for her medication safety work on behalf of OhioHealth, a family of not-for-profit, faith-based hospitals and healthcare organizations serving patients in central Ohio. Kelly is a medication safety coordinator for the health system. She will receive the award in May for her outstanding efforts and progress toward furthering medication safety

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