The following are excerpts from the newsletter

January 24, 2013

  • Survey results: How hospitals are managing the preparation and purchase of high-risk compounded sterile preparations (CSPs)

  • NAN ALERT: Remove “glacial” acetic acid now! 
    Numerous medication errors have occurred after failing to recognize that “glacial” acetic acid is the most concentrated form (≥ 99.5%) of acetic acid. The item was either accidentally purchased or used in place of a much more diluted form of acetic acid, such as vinegar or commercially available 0.25% solution. This has resulted in severe harm including severe pain and serious tissue damage, third-degree burns, and in one case, bilateral leg amputation. ISMP has published a warning through the National Alert Network (NAN). This can be viewed 
  •  Safety Briefs: Tamiflu suspension dosing confusion, again?
    Genentech has Tamiflu 6 mg/mL oral suspension in 60 mL bottles on intermittent back order, so pharmacies may be compounding an extemporaneous 6 mg/mL oral suspension from 75 mg capsules per the manufacturer’s instructions. However, the commercial oral suspension was previously available in a 12 mg/mL concentration, and the manufacturer’s previous extemporaneous compounding instructions produced a 15 mg/mL product.

  • Safety Briefs: Insulin pens again used on multiple patients
    Over 700 patients at a hospital in New York State may have been exposed to HIV, hepatitis B, or hepatitis C because of accidental reuse of insulin pens between October 2010 and November 2012.

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