The following are excerpts from the newsletter

February 23, 2012

  • Smart pump custom concentrations without hard “low concentration” alerts A perfect storm for patient harm
  • Safety Brief: Bortezomib deaths due to misadministration. Bortezomib is fatal if given intrathecally. At least three medication errors with bortezomib have been reported in Europe since 2003, all resulting in death. Unfortunately, we are unaware of studies that support dilution of bortezomib in volumes unsuitable for intrathecal injection, a tactic adopted by many healthcare settings in the US to prevent vinCRIStine errors. Complete recommendations for prevention of errors with vinCRIStine, most of which should be adopted for bortezomib, are available at:
  • Safety Brief: Do not infuse Cosmegen in sterile water. According to the new label for COSMEGEN (DACTINomycin), studies conducted on the lyophilized powder demonstrate that solutions diluted at concentrations of 10 mcg/mL or higher in sterile water for injection, 0.9% saline, and 5% dextrose in glass or PVC infusion containers are chemically stable for up to 10 hours when stored at ambient room temperature. But diluted with a large volume of sterile water for injection, the solution would have an osmolality in the low single digits! Although the manufacturer does not specifically state that DACTINomycin in sterile water for injection is suitable for IV infusion, someone may believe it is safe, which it is not.
  • Safety Brief: Culture still needs work. According to an Agency for Healthcare Research and Quality (AHRQ) survey, half of nearly 600,000 hospital staff surveyed at more than 1,110 hospitals nationwide said they believe their mistakes are held against them and that, when the mistake is reported, it feels like “the person is being written up, not the problem.” When it comes to a culture of safety in healthcare, it looks like we still have a long way to go.
Special Announcements
  • ISMP webinar. Join ISMP on March 6 for Reducing Hospital Readmissions Through Medication Use Optimization. Learn about medication-related readmission reduction programs that have been implemented at two hospitals and the impact it has made on readmission rates and patient care. For details, visit:
  • A.S.P.E.N. collecting new data on PN drug shortages. Last summer, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) conducted a survey on parenteral nutrition (PN) shortages you were encountering in clinical practice. This month, the organization is repeating this short nine-question survey though March 13, so it can provide new data to the FDA Drug Shortages Program and support current drug shortages legislation. Please participate in the survey at:  

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