Prenteral nutrition error [from #ISMP]

From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

The big difference between these two is how you order electrolytes; it’s a really big difference.

The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?

Read more

2012 ISMP Med Safety Self Assessment for Oncology now available

The Institute for Safe Medication Practices (ISMP), ISMP Canada and the International Society of Oncology Pharmacy Practitioners, have launched the 2012 ISMP International Medication Safety Self Assessment for Oncology. The tool is used to “identify a baseline of oncology-related medication practices and opportunities for improvement.” ISMP is asking that any practice setting that administers chemotherapy … Read more

Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

When I read the headline in the most recent ISMP Medication Safety Alert! – Smart pump custom concentrations without hard “low concentration” alerts – I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense. … Read more

Don’t confuse Durezol and Durasal (S.A.L.A.D.)

PharmQD: “FDA is alerting pharmacists and other health care professionals of potential injury due to confusion between the FDA-approved eye medicine Durezol (difluprednate ophthalmic emulsion) 0.05% and the unapproved prescription topical wart remover Durasal (salicylic acid) 26%. There has been one report of serious injury when a pharmacist mistakenly gave an eye surgery patient Durasal, … Read more

ISMP launches first self assessment of ADC safety “More than 80% of US hospitals have implemented automated dispensing cabinets (ADCs) as an important part of their drug distribution system, making the evaluation of practices surrounding this technology an essential step in ensuring patient safety. To help meet healthcare organizations’ growing need for assistance in this area, ISMP has introduced the first Medication … Read more

Problems with barcodes.

ISMP Medication Safety Alert! May 21, 2009 Vol. 14, Issue 10: “Please let us know if you identify problems with  a company’s unit dose package barcode. An example of an ARICEPT (donepezil) unit-dose package with a barcode  problem appears in Figure 1 (shown in the PDF version of the newsletter). Note that the labeling material has been applied to the … Read more