The following are excerpts from the newsletter

March 21, 2013

  • Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit
  • Safety Briefs: Methadone selected from computer screen in error
    A nurse gathering drug history on a new ED patient inadvertently selected methadone 100 mg BID from the computer screen instead of metoprolol 100 mg BID. During the admission process, the physician reviewed the patient’s medication list and wrote orders to continue all medications. The pharmacist processing the orders questioned the physician regarding the high dose of methadone, but the physician failed to specify the indication and stated that the medication should be given as written. After receiving 2 doses of methadone 100 mg, the patient experienced a cardiorespiratory arrest.
  • Safety Briefs: Handwritten order mistaken for methadone
    A patient received methadone for several days instead of the intended diuretic metolazone due to a misinterpreted handwritten order.
  • Last Call: Fellowship applicants
    Applicants have until 11:59 p.m. on April 1 (or postmarked no later than March 30) to submit an application for one of three 2013-14 ISMP Safe Medication Management Fellowship(s). For a program outline, application, and contact information, please visit:
  • ISMP Webinar
    Join us for our April 23 webinar, Safety Strategies with Oral Chemotherapy. For details, visit:

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