January 12, 2000

• Misidentification of alphanumeric characters
• Fortune 500 company benefit plans adopting standards for computerized physician order entry
• Safety Briefs
• Continued confusion between SUFENTA (sufentanil) and SUBLIMAZE (fentanyl) has resulted in multiple episodes of respiratory arrest.
• Glaxo Wellcome revamps labeling of ALKERAN (melphalan), LEUKERAN (chlorambucil), and MYLERAN (busulfan) to minimize the risk of confusion.
• Use of prescription labels in areas other than the pharmacy may lead to inappropriate use on non-drug items. Only blank labels should be made available outside the pharmacy.
• PROCANBID (procainamide hydrochloride extended release) releases procainanamide steadily over 12 hours therefore the dosing interval should not be more frequent than every 12 hours. Although PROCAN SR (procainamide hydrochloride sustained release), which is given every 6 hours, was recently withdrawn from the market, generic versions are still available and may continue to be ordered by the former brand name. The two forms of procainamide are not substitutable with each other.
• The monographs for cytarabine, daunorubicin, and doxorubicin in Drug Facts and Comparisons have been revised to clearly delineate the conventional and liposomal forms.
• Sublingual nifedipine has been rejected by experts as an unsafe practice (see ISMP Medication Safety Alert! November 6, 1996). However some physicians are still administering nifedipine sublingually, although suitable effective alternatives are available.
• Reminder! Now that another year has passed, be sure to update the drug reference texts used in the pharmacy and patient care units, and don't forget to discard the outdated references.
• Announcements
• We are pleased to announce that Allen J. Vaida, Pharm.D., has joined ISMP as an executive director. Dr. Vaida, who has served as a trustee for ISMP since its founding, is a seasoned healthcare administrator and clinician.
• ISMP announces the availability of the 2000-2001 Safe Medication Management Fellowship. The one-year fellowship program trains a nurse, pharmacist, or physician with at least one year of clinical experience in methods for preventing adverse drug events. The fellow works closely with ISMP staff on a variety of educational activities and visits practice sites, regulatory agencies, and pharmaceutical manufacturers. Call us at 215-947-7797 for a syllabus and application.

January 26, 2000

• Optimizing the use of computer system clinical alerts
• ISMP Quarterly Action Agenda: October - December 1999
• Safety Briefs
• FDA Medwatch asks partners to communicate two new warnings
1. The black box warning about well-known serious cardiac events associated with PROPULSID (cisapride) now includes recommendations to obtain a 12-lead ECG before administration and to avoid initiating treatment if the patient's QTc value exceeds 450 milliseconds.
2. There is a newly revised warning for the antiretroviral drug ZIAGEN (abacavir sulfate). Fatal hypersensitivity reactions have occurred in patients who have presented with respiratory symptoms (including cough, dyspnea, or pharyngitis), and who were initially diagnosed with an acute respiratory disease (pneumonia, bronchitis or flu-like illness).
• A new conceptual framework for adverse event and error reporting, developed by ISMP, was presented at an educational briefing in Washington, D.C. for Senate staff and organizational representatives on Monday, January 24 by ISMP, with the American Hospital Association and the American Pharmaceutical Association. An executive summary of the ISMP conceptual framework is available on our web site.
• In a recent study (Golder M, Chan CLH, O'Shea S et al. Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets. Lancet 2000;355:44) a high proportion of tourniquets used to promote venous stasis for IV cannulation and phlebotomy were found to be contaminated with blood and bacterial pathogens.
• In our November 17, 1999, issue, we suggested that those committed to medication error reduction could learn much from the vast body of knowledge, research, and experience gained through infection control efforts. Research confirmed that hospitals with the lowest nosocomial infection rates had BOTH strong surveillance programs AND prevention/control programs (Haley RW, et al. Am J Epidemiol 1985; 121:182-205). Today, regulatory, accrediting, and other infection control advisory bodies recommend that hospitals employ specifically trained, dedicated practitioners to identify the presence of nosocomial infections AND coordinate an effective infection control plan. The recent report from the Institute of Medicine (Kohn LT, Corrigan JM, Donaldson MS editors. To err is human. Building a safer health system. Washington, IOM, 1999) also recognizes the value of devoting human and financial resources to error analysis and system redesign. The report notes that individuals or departments "own" a piece of the medication system, but as a rule, no one manages the system as a whole. In discussing key safety design concepts, the IOM report notes that oversight of the hospital's medication system might be placed under a single clinician, with 50% or more of his or her time devoted to this role (pg. 145). ISMP strongly supports this concept and encourages organizations to gain leadership backing and financial support for such a position. With budget preparation around the corner, now may be a good time to begin discussions on this important issue.
• A 61-year-old man developed hepatocellular injury after taking AVANDIA (rosiglitazone) for two weeks. (Al-Salman J et al. Hepatocellular injury in a patient receiving rosiglitazone. A case report. Ann Intern Med 2000;132:121-4)

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