The following are excerpts from the newsletter

September 8, 1999

• HESPAN and heparin mix-ups - reduce the risk by using generic name and product
• Major drug interaction missed by many physicians and pharmacists
• ISMP and hospital group holding full day session to discuss practical solutions to error problem
• Safety Briefs:
  • Roche Laboratories has notified pharmacists about reports of mix-ups between their products XELODA (capecitabine), an oral antineoplastic agent, and XENICAL (orlistat), an oral antiobesity agent.
  • New name mix-up betweeen AVANDIA (rosiglitazone) and PRANDIN (repaglinide) reported. Both medications are indicated for type 2 diabetes mellitus.
    
    Picture of order for AVANDIA
  • Correction: In the article "Patients must demonstrate comprehension of medication instructions" (ISMP Medication Safety Alert! June 16, 1999), we incorrectly stated that a child given 2.5 mL of digoxin pediatric elixir (0.05 mg/ml) received 150 mcg per dose. The stated dose should have been 125 mcg.
  • Lexi-Comp's current Drug Information Handbook for Oncology (Lexi-Comp, Inc. Hudson OH 1999) a dose of vincristine is listed ambiguously.
  • Same problem, another death: Another accidental overdose of BREVIBLOC occurred when an OR nurse miscalculated a loading dose and both the ampuls and vials were available.
  • Same old, same old. We've also had another mix-up reported between lipid-based amphotericin B and conventional amphotericin B.

September 22, 1999

• Use of peritoneal dialysis solution requires understanding of physiology behind process
• Four-pronged error analysis is "best practice"
• Safety Briefs:
  • In cooperation with the Medication Errors Division of FDA's Office of Postmarketing Drug Risk Assessment (OPDRA), Monarch Pharmaceuticals, a division of King Pharmaceuticals, has relabeled all strengths of KETALAR (ketamine) injection to reduce medication errors.
    
    
    
    Picture of new Ketalar packaging
  • Rather than develop or revise an approved list of medical abbreviations, JC allows you to deem a medical abbreviation dictionary as the standard. Still, for patient safety, you should have a list of dangerous abbreviations that should never be used.
  • FDA does not require companies to forward potential errors with product labeling, packaging, and names when reported by practitioners. To assure FDA, ISMP, and USP awareness, report to the USP-ISMP Medication Errors Reporting Program (800 23 ERROR) or FDA MEDWATCH Program (1-800-FDA-1088).
  • CDC has learned of numerous cases of inadequate treatment of syphilis with BICILLIN C-R (a mixture of 1.2 million units each of penicillin G benzathine and penicillin G procaine). Instead, BICILLIN (which contains only penicillin G benzathine) 2.4 million units should have been used.

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