The following are excerpts from the newsletter

February 21, 2013

  • A clinical reminder about the safe use of insulin vials
  • Safety Brief:  A woman admitted status-post subarachnoid hemorrhage was placed on oral niMODipine 60 mg every 4 hours. Due to the disease process, she had a nasogastric tube (NG) inserted. However, the admission orders did not reflect this, and the pharmacy was not aware the drug was being given via the NG tube.
  • Safety Brief:  An unfortunate yet common issue that comes up during computer order entry is inadvertently picking the wrong drug from a drug name search list. For example, a prescriber may wish to enter an order for acetaminophen by typing “aceta,” but then accidentally choose acetaZOLAMIDE from the search results.

  • Safety Brief: When reviewing your electronic or preprinted order sets, be sure to keep in mind that the US Food and Drug Administration (FDA) is requiring manufacturers that make zolpidem (AMBIEN and generics) to lower the approved doses of the drug.

  • Safety Brief:  A child diagnosed with congenital hypothyroidism had been receiving levothyroxine (T4; SYNTHROID) for the first year of life with adjustment of his medication as necessary. At around 14 months, the child had significantly abnormal laboratory values with what appeared to be a central hypothyroidism profile (low TSH, low free T4). It took many months to figure out that the pharmacy was dispensing liothyronine (T3; CYTOMEL) instead of levothyroxine, causing the child to develop a significantly elevated T3 level (greater than 500 nanogram/dL).

    Special Announcements 

    • ISMP Webinars. ISMP will be holding webinars titled Reducing IV Admixture-Related Safety Risks: Implementation of the ISMP Guidelines for SAFE Preparation of Sterile Compounds on March 14, 2013 and Safety Strategies with Oral Chemotherapy, on April 23, 2013. For details about both webinars, please visit:
    • Attend ISMP’s Medication Safety INTENSIVE workshop, an interactive program that provides a basis for effective approaches to medication safety. Sharpen your risk assessment and event investigation skills, and learn more about Just Culture, Lean Six Sigma, high leverage error-reduction strategies, and more. The workshop will be held in Tampa, FL, on March 7-8. For details, please visit:
    • Fellowship opportunities. ISMP is now accepting applications for three 2013-2014 Fellowships. The year-long Fellowships allow the candidates to gain experience in medication error prevention initiatives. One Fellowship is tailored to a PGY4 physician resident and includes a local hospital safety rotation. The second Fellowship provides on-site experiences with both ISMP and the US Food and Drug Administration. The third Fellowship provides a candidate with an opportunity to work with interdisciplinary professionals on national and local medication safety projects. For details, please visit:

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