The following are excerpts from the newsletter

March 7, 2001

• To err is human, to improve divine: A New Health System for the 21st Century
• What would nurses at ISMP do differently if they returned to the bedside?
• Safety Briefs
  • Pharmacy oversight is essential if the central supply department is distributing any floor stock IV solutions to patient care units.
  • Anesthesia professionals have been hit hard by the nationwide shortage of anesthetics and muscle relaxants.
  • Last Friday, March 5, the American Society of Anesthesiology contacted the FDA and US Drug Enforcement Agency, the Pharmaceutical Research and Manufacturers of America, and several anesthetic manufacturers and distributors asking them to participate in an immediate fact-finding mission to put an end to the critical drug shortage.

March 21, 2001

• National survey on drug shortages reveals high levels of frustration, low regard for safety
• IV administration set spiked into enteral nutrition container
• Safety Briefs
  • Most patients do not want to be "protected" from information about all possible adverse effects of prescribed medications.
  • Recently, a vial of U-500 insulin was left in a nursing unit refrigerator after the patient for whom it was prescribed went home. While looking for regular insulin in the refrigerator, a nurse saw the familiar brand name, HUMULIN R (regular insulin) but did not notice the U-500 concentration

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