The following are excerpts from the newsletter

September 11, 1996

• Case studies sought for OTC drug error project
• Medication error council promotes error prevention recommendations
• Off-beat drug error at health food store indicates new area of concern with OTC items
• Safety Briefs
  • Another Chloral Hydrate Overdose
  • Long term use of triazolam found in DUE
  • Hazard from blister wrapped unit dose capsule
  • Mix up of lamotrigineand lamivudine
  • New medication compliance reminder device

September 16, 1996

Special Error Prevention Advisory

September 25, 1996

• New Strategies required to prevent esmolol related accidental deaths
• Avioiding metformin induce lactic acidosis
• Ongoing chemotherapy errors: System failures that compromise patient safety
• More Camptosar (irinotecan) errors
• Say no no to "cc"
• Safety Briefs
  • Denver hospital reviewing drug control procedures
  • Lodine confused with iodide
  • Estratest HS and Estratest have different dosing schedules
  • PreCare® Caplets mistaken for Precose®

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