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The following are excerpts from the newsletter


October 3, 2001

  • Systems thinking: Tap into staff creativity to unleash innovation
  • ISMP Quarterly Action Agenda: July - September 2001
  • Safety Briefs:
    • Naloxone 0.4 mg/mL and heparin 5,000 units/mL packaged in Abbott's prefilled Carpuject syringes are very similar in appearance to boxes of phenytoin 100 mg/2 mL Carpujects.
    • An elderly woman was prescribed amitriptyline to treat a neurogenic pain syndrome, but her physician didn't tell her why it was being prescribed or write the reason for the medication on the prescription.. While counseling the patient, a pharmacist described the medication as an antidepressant. The patient became angry, refused the medication, and accused her physician of believing her pain was all in her head.
    • Guidance regarding bioterrorism preparedness and response can be found at the Johns Hopkins Center for Civilian Biodefense Studies web site ( and the Centers for Disease Control and Prevention emergency preparedness web site (
    • We are now accepting nominations for the 2001 ISMP Medication Safety Alert! Subscriber Award to honor an organization that has proactively used this publication to improve medication safety.
    • ISMP hosts the 4th Annual Cheers and Lifetime Achievement Awards Dinner and Reception at 6 p.m., December 4, 2001, during the ASHP Midyear Clinical Meeting at the Hilton New Orleans Riverside. James P. Bagian, MD, PE, Director of the Department of Veterans Affairs National Center for Patient Safety, will be the keynote speaker. Lucian L. Leape, MD, internationally renowned expert on medical errors and prevention efforts, will receive the first annual ISMP Lifetime Achievement Award.

October 17, 2001

  • Failure Mode and Effects Analysis can help guide error prevention efforts
  • Insulin syringe is not meant for U-500 insulin
  • Safety Briefs:
    • Congratulations to those who report medication safety issues to USP, ISMP and FDA. As a result, several longstanding medical product safety issues have been resolved. Eisai and Janssen have changed the package label appearance for ACIPHEX (rabeprazole sodium) to help differentiate it from ARICEPT (donepezil), one of their other products.
      Also, Merck has addressed problems you've been reporting about look-alike unit dose packaging. They've reduced the risk of product misidentification by using distinct color schemes for products within the same classification with alternating geometric shapes and reversed backgrounds to highlight product strengths. PRINIVIL (lisinopril), PROSCAR (finasteride) and ZOCOR (simvastatin) label changes have been introduced already, as these products have been associated with dispensing errors most frequently.

      Also, you may have seen recent journal advertisements announcing that GlaxoSmithKline has substantially changed the container labeling to reduce the potential for dispensing errors due to confusion between its antiepileptic drug, LAMICTAL (lamotrigine) and LAMISIL (terbinafine), a Novartis product. The new label highlights the ".ICTAL" part of the name by italicizing it and placing it in a yellow background with red characters (LAMICTAL). In addition, a message has been placed on the front label panel stating: "CAUTION: Verify Product Dispensed." Finally, Andrx Laboratories has discontinued use of the proprietary name PROCET for its hydrocodone bitartrate and acetaminophen tablets. Instead, the trademark ANEXSIA will be used with this product. In our September 5, 2001 issue, we mentioned Procet as an example of a loophole in federal regulations that allows generic firms to avoid trademark review by FDA if they distribute a drug but do not hold the abbreviated new drug application (ANDA) which, in this case, is held by Mallinckrodt. FDA now intends to close that loophole through issuance of a guidance statement. We thank the companies and FDA for taking action on the concerns expressed by our reporters. But most of all, we thank you for reporting product-related concerns.
    • Another tragic death caused by concomitant use of low molecular weight heparin (LMWH) and unfractionated heparin another tragic death caused by concomitant use of low molecular weight heparin (LMWH) and unfractionated heparin reported to ISMP.
    • Education provided to patients while in the physician's office can arm them with the information needed to prevent errors.
    • ABC News recently reported that four people were arrested after breaking into a veterinarian's office to search for OXYCONTIN (oxycodone, controlled release). Instead, they oxydentally took oxytocin).
    • Based on a single letter sent to the managing editor of American Diabetes Association professional journals, a new policy to prohibit the use of the abbreviation "U" for units has been instituted. Packaging changes for ACIPHEX (rabeprazole sodium), and ARICEPT (donepezil HCl), lead to near miss.
    • Survey on practice site distribution of the ISMP Medication Safety Alert!

October 31, 2001

  • To promote understanding, assume every patient has a health literacy problem
  • Action needed to prevent dangerous Zyrtec-Zyprexa mix-ups
  • Safety Briefs:
    • An Ohio pharmacist has been indicted by a local grand jury for dispensing a fatal overdose of chemotherapy to a patient with multiple myeloma.
    • A neonatal intensive care unit nurse called the pharmacy she stated that she needed "A PRISCOLINE (tolazoline) drip," but the pharmacist misunderstood her to say "APRESOLINE drip" (hydralazine).
    • A patient was ordered REMICADE (infliximab) via IV pump. Unfortunately, the tubing from a bag of saline that also was hanging on the IV pole was accidentally threaded through the pump instead of the intended solution. As a result, the Remicade solution infused at an uncontrolled rate.
    • A hospital reported mix-ups between two different "rubicin" products (anthracyclines).

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