january 14, 2010

• Survey shows recession has weakened patient safety net
• Neuromuscular blocker mix-up in the pharmacy
  
  ISMP received a report in which vecuronium was accidently used instead of valproate sodium injection to prepare two infusions.  Read more about this incident and ISMP’s recommendations for how to reduce errors with neuromuscular blockers.

• Safety Brief: “UD”—an ambiguous and dangerous abbreviation.
  
  A serious error resulted when a nurse misunderstood the meaning of the abbreviation “UD.”  Learn what “UD” was misinterpreted to mean and if this could be an issue within your own organization.
  
• Safety Brief: Order by metric weight, not volume.
  
  In most cases, it is unacceptable to express doses or quantities in terms of dosage form or volume alone.  Check out this issue of the newsletter to review the few exceptions in which it may be acceptable to prescribe by volume alone.
  
• Safety Brief: Unrecognized peel-back labels on OTC drugs.
  
  ISMP received a report involving a patient who was unable to find dosing instructions for an OTC product on the bottle’s label. Directions for use, as well as other drug facts, are actually located underneath a label overlay that must be peeled back to expose the information.  Read more about ISMP’s concern regarding this issue in this week’s newsletter.

• ISMP and Doctor’s Digest launch new iPhone application.
  
  In cooperation with the publication Doctor’s Digest, ISMP has launched PracticeRx, a free safety alert system and error-reporting tool for the iPhone. If you have an iPhone you can download the free application now using iTunes or your iPhone. Go to: http://itunes.apple.com/us/app/practicerx-bydoctors-digest/id345767265?mt=8.
  Be sure to download the application today!
• ISMP employment. 
  
  ISMP is seeking a pharmacist (PharmD or Master’s degree) or nurse (Master’s degree) with at least 5 years clinical and managerial experience for a fulltime position as a Medication Safety Specialist in our consulting division in Horsham, PA.  For information, visit www.ismp.org/jobline/mse.asp and send your resume and salary requirements to ismpinfo@ismp.org.
• ISMP webinar. 
  
  Please join us on February 18, 2010, for Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets (ADCs). Preliminary data since the launch of the self assessment will be presented along with recommendations to further improve the safe use of ADCs. For details, please visit: www.ismp.org/educational/webinars/default.asp.
• Deadline extension.
  
  The application deadline for ISMP’s 2010-2011 Safe Medication Management Fellowship sponsored by Cardinal Health Foundation (www.ismp.org/profdevelopment/managementfellowship.asp) and the 2010-2011 FDA/ISMP Safe Medication Management Fellowship (www.ismp.org/profdevelopment/fdaismpfellowship.asp) is now March 1, 2010.
• Fellowship conference call.
  
  Please join us on January 26, 2010, at 1:00 p.m. ET for a special conference call about the Fellowship program. Current and past Fellows will describe their experiences and answer questions. To attend, send an email to Rebecca Lamis, the current ISMP Fellow, at: ismpinfo@ismp.org.
  

january 28, 2010

• Baclofen programming error with SynchroMed II pump
  Facility not made aware of company’s software updates
• Safety Brief: Problematic bar code.

  The Veterans Health Administration Bar Code Resource Office has alerted us to an issue regarding scannability of a topical fluorouracil product.  Check out the newsletter to find out if this is a product you utilize at your facility and how this scanning issue may affect your organization.

• Safety Brief: “Catching deadly drug mistakes.”
  
  On January 18, 2010, the Wall Street Journal published an article entitled, “Catching deadly drug mistakes” (http://online.wsj.com/article/SB10001424052748703626604575010932945077528.html), which touched on the National Alert Network for Serious Medication Errors (NAN) that ASHP is coordinating with ISMP, ISMP’s efforts to address medication errors, and a new effort by The American Association of Eye and Ear Centers of Excellence to improve labeling of ophthalmic and otic solutions. 
• Safety Brief: A different type of allergy problem.
  
  During a hospitalization, “vitamin D” was entered into the allergy field of a patient’s medical record, although the patient had never reported any adverse effects from the vitamin.  On subsequent medical visits, the erroneous information remained in the patient’s medical record even after repeated requests for its removal.  Learn why this information was not corrected and if this may be an issue within your healthcare organization.

• March 7-13: Patient Safety Awareness Week.
  
  If you are planning events for patients, community groups, or area businesses, consider showing Patients Play a Vital Role in Patient Safety, a video distributed by ISMP. The program is just 20 minutes long, but it covers realistic scenarios of risks, and practical, expert advice to help patients become active participants in their own care and safety. Hospitals are also encouraged to show this video on their patient education channel; suggested viewing locations include preadmission testing and outpatient waiting areas. To order a copy, visit: http://onlinestore.ismp.org/shop/item.aspx?itemid=146.
• ISMP webinar. 
  
  Please join us on February 18, 2010, for Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets (ADCs). Preliminary data since the launch of the self assessment will be presented along with recommendations to further improve the safe use of ADCs. For details and to register, please visit: http://www.ismp.org/educational/webinars.asp.

subscribe now