The following are excerpts from the newsletter

August 11,1999

• Measuring medication safety: What works? What doesn't?
• Hazard Warnings!
• Writing patient name and location on commercial unit dose product label may foster errors
• Safe Medication Management Fellow welcomed
• Safety Briefs:
  • USP and USAN propose name change for amrinone and amiodarone
  • Tip for preventing dispensing errors. Use of highlighter to make sure nothing is overlooked.
  • Our new medication errors book contains section on detecting and measuring errors with various "high alert" medications
  • Gilead Sciences seeks alternate trademark for adefovir dipivoxil, an oral reverse transcriptase inhibitor for AIDS in order to prevent name mixups.
  • Pharmacia and Upjohn's proposed trademark for a new antibiotic, ZYVOX (linezolid), is likely to be confused with Merck's new COX2 inhibitor, VIOXX (rofecoxib).
  • The Pharmaceutical Research and Manufacturer's Association (PhRMA) and FDA are participating in a "Paperless Labeling Task Force." The task force is seeking to replace the current paper package insert with constantly updated electronic versions (PDF files), available exclusively to health professionals via FDA's web site.

August 25,1999

• Near-fatal pediatric accident should force reassessment of a common cost-cutting measure
• Preventing mix-ups between pediatric and adult medication concentrations
• Safety Briefs:
  • NIMOTOP (nimodipine) capsule given IV to patient who could not swallow instead of via naso-gastric tube.
  • Recommnedation for avoiding dangers with hypertonic solution mix-ups.
  • Keep safety in mind when labeling the contents of drug storage bins in patient care units. Par levels can be mistaken for drug dosages or strengths.
  • The dispensing accuracy of ROBOT-Rx from McKesson- HBOC Automated Healthcare is impressive, but the system can still allow errors.
  • Medfusion pumps can be programmed to deliver an accurate bolus dose, which is then added to the total volume infused, if the "bolus" operation is selected and programmed correctly.
  • Did you know that our web site (www.ismp.org) has a very active message board for health professionals?

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