ISMP: Common Workaround Contributes to Override of Barcode Alert
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A specialty pharmacy filled a prescription for Jakafi® (ruxolitinib) 5 mg tablets with 15 mg tablets by mistake and shipped it to the patient. Jakafi is a kinase inhibitor used to treat myelofibrosis and polycythemia vera in adults, and graft-versus-host […]
Read More ›ISMP: Restarting Clozapine Too Rapidly Can Cause Severe Cardiovascular Effects
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A patient presented to a hospital with agitation and confusion. He had a history of bipolar disorder for which he had been prescribed (off-label) the antipsychotic clozapine (CLOZARIL®). However, he had not taken the clozapine for several weeks more than […]
Read More ›ISMP: Respond to consumers’ error concerns with empathy and honesty
This column was prepared by the Institute for Safe Medication Practices, an ECRI affiliate. The Institute for Safe Medication Practices (ISMP) receives frequent reports of medication errors directly from patients. While patients are understandably concerned about errors, the patients who report to us are usually more upset about the response (or lack of) from the […]
Read More ›ISMP Provides Safe Practice Recommendations to Prevent COVID-19 and Flu Vaccine Mix-Ups
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. Multiple mix-ups between the pediatric formulation (ages five through 11 years; orange cap and label border) and the formulation for individuals 12 years old or older of the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) Vaccine have been reported to the Institute […]
Read More ›ISMP Warns of Possible Confusion With InPen Insulin Pen Systems
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. The Institute for Safe Medication Practices (ISMP) has received a report from an outpatient pharmacy regarding a close call with a product called InPen a Bluetooth-connected “smart” insulin pen system for mealtime insulins that is prescribed with either insulin aspart […]
Read More ›Pharmacies Can Address These Two Hazards to Improve Safety Programs
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. Every pharmacy should strive to continually improve their medication-use system and provide the safest, highest quality of care possible. To accomplish this, practice sites must assess their risks associated with the medication-use process by monitoring actual and potential medication errors […]
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