The following are excerpts from the newsletter

February 7, 2001

• FDA Advise-ERR: Medication errors associated with Taxotere and Taxol
• Depakote ER - easy to confuse with Depakote (delayed release)
• Safety Briefs
  • Recent national shortage of fentanyl products presents potential problems when substituting sufentanil.
  • Mark Twain said, "Be careful about reading health books. You may die of a misprint."
  • Preliminary report of findings from the ISMP Medication Safety Self Assessment^TM is now available for participants who submitted data to ISMP.
  • Trailing zeros on prescription labels may lead to further error.

February 21, 2001

• Hazard Alert! Action needed to avert fatal errors from concomitant use of heparin products
• Sidestepping dispensing errors with newly marketed drug products
• ISMP announces 10th annual fellowship program
• Safety Briefs
  • Symbols increase the risk of medication errors. They require the reader to translate into words what the user "assumes" will be the correct understanding of the symbol.
  • Braintree Laboratories has prominently attached an advertisement for MIRALAX to the neck of the 4 liter disposable container of GOLYTELY. Many elements of the ad look like a product insert. A pharmacist recently expressed concern that patients in the ambulatory setting may incorrectly interpret MiraLax's dosage and administration instructions as those meant for GoLYTELY
  • Drs. Kenneth Barker, Betsy Flynn, and colleagues presented information from a recent study on various medication error detection methods in 24 hospitals and 12 skilled nursing facilities at the ASHP Midyear Clinical Meeting. Auburn University recently made a commitment to make their direct observation methodology for detecting errors available to hospitals that wish to install it as an ongoing quality improvement feature

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