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MEDICATION SAFETY
Medication Safety is a series of articles that are published in the Journal of Pharmacy Practice and Research. They provide up-to-date information about medication safety issues and strategies to prevent medication errors. The incidents reported are drawn from Australian experience and from the Institute for Safe Medication Practices (ISMP), USA.
Click on the dates below to download the Medication Safety section of these issues of the Journal of Pharmacy Practice and Research in PDF format.
September 2008
Topics include:
Thyroxine confusion
IV potassium chloride errors - AGAIN!
New extended release tramadol - potential for confusion
Magnesium/potassium look-alike confusion
HIV prophylaxis - beware drug interactions
Technology brings new problems - insulin error
Epidural/IV mix-ups
Avoid confusion with temsirolimus preparation
Managing visits from pharmaceutical sales reps
Tall man letters to reduce drug confusion
Fatal vindesine event
June 2008
Topics include:
Sequential patch application
Minax (metoprolol) confused with minocycline
Mixture strengths - a source of error?
Glyceryl trinitrate patches - lack of standardised labelling contributes to errors
Patient identification traps
Take care when using information from a prescription label
Penicillin suspension change of strength
Nexavar (sorafenib) confused with Nexium (esomeprazole)
Safe methadone use
HOPA - ISOPP - ISMP chemotherapy safety survey
Insulin pens for hospital use - what are the risks?
Heparin shortage - potential for errors
Tragic mix-up — propylthiouracil and Purinethol
March 2008
Topics include:
Oxycodone confusion - oral liquid administered subcutaneously
Heparin overdose due to verbal order confusion
Insulin a high-risk medication - 2 cases of 10-fold overdose
Desmopressin - change of route needs a change in dose
Dangers of unlabelled syringes
Don't rely on medication history from a confused patient
Sterile water and 0.9% sodium chloride mix-up
Refrigerator monitoring
Camphor and childhood seizures
December 2007
Topics include:
Heparin concentration error in a child
Confusion with IV electrolyte order
Wife takes husband's cytotoxic
Coumadin (warfarin)/Coversyl (perindopril) dispensing error
IV Amphotericin B - lipid vs conventional dose confusion
Fatal zinc overdose in premature neonate
WHO: dilute vincristine in a minibag
Fatal fluorouracil infusion rate error
Ceftriaxone/calcium warning
Prozac (fluoxetine)/Prograf (tacrolimus) confusion
T1D (T-one-D - type 1 diabetes) or TID?
September 2007
Topics include:
Oral mercaptopurine given IV with oral syringe
New COX-2 inhibitor cumerone - beware similar drug names
Ongoing preventable fatalities with fentanyl patches
New ceftriaxone warning
Oral solution given IV
Another intrathecal vincristine death
2007
March | June
2006
March | June | September | December
2005
March | June | September | December
2004
March | June | September | December
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