The following are excerpts from the newsletter
- Patient safety is
all about taking that extra step.
- Suggestions for resolving
conflicts in drug therapy.
- ISMP Quarterly
Action Agenda: April - June, 2001
- Safety Briefs:
- There is a developing nomenclature issue with LANTUS
[insulin glargine (rDNA origin)], a new insulin product
approved for use in both type 1 and type 2 diabetes mellitus.
- Seventeen reports of medication errors due to confusion
between SERZONE (nefazodone), an antidepressant, and SEROQUEL
(quetiapine), used for psychotic disorders.
- An article in the July, 2001 Hospital Pharmacy shows
that vincristine is stable when diluted to 20-50 mL. Such
dilutions can help in preventing inadvertent fatal intrathecal
injection since it makes it look different than typical
intrathecal drugs which are usually given in volumes of
10 mL or less.
- A mix-up between AVANDIA (rosiglitazone maleate), an
antidiabetic agent, and COUMADIN (warfarin). The patient
says he developed a GI bleed and required a bowel resection.
- A "heads up" to look at current procedures for securing
needle disposal boxes in patient care areas. According
to a reporter, there have been several arrests made in
the Kansas City, KS after patients stole boxes from nursing
units in order to extract leftover narcotics from used
- The supermarkets
do it - so why can't we raise the "bar" in health care?
- A hospital recently reported a situation where house
staff incorrectly ordered AGGRASTAT (tirofiban) when they
meant to order argatroban.
- Safety Briefs:
- A patient with renal failure was given a dose of vancomycin
along with orders to administer another 1 g dose intravenously
if his vancomycin level the next morning was "less that
10." The symbol for "less than" was written in a way that
made the number 10 look more like 40.
- An office nurse telephoned a prescription to a community
pharmacy for "Trydesogen-28," giving directions for the
patient to take one tablet daily. The pharmacist called
to clarify the order. The nurse decided to check with
the doctor, who was overheard in the background saying,
". no, no, I said to try DESOGEN (ethinyl estradiol and
- The Agency for Healthcare Research and Quality (AHRQ)
released a 640-page report last week, detailing evidence-based
practices known to improve patient safety. The AHRQ report
lists more than 70 practices, including the top eleven
proven practices yet to be widely adopted by hospitals.
- At one hospital, if items were not available commercially
in unit dose packaging, a 24-hour supply was placed in
a single, zip-lock bag and sent in a patient drug bin
with the drug cart each day at 1500. It became apparent
that some nurses, familiar with unit dose packages that
hold only one dose, might have confused the contents of
the multi-dose zip-lock bags as a unit dose package.
- The free ePocrates qRx drug database (www.epocrates.com)
is a database that provides adult and pediatric dosing,
dosage strengths, drug interactions, adverse reactions
and contraindications, metabolism and excretion, and pregnancy
and lactation information