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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.

June 2010 (download) 

Topics include:

• Over-prophylaxis against VTE?
• Beware: look-alike products
• Preventing errors administering drugs via enteral feeding tubes
• Vaccine error detecting by recording lot numbers
• Lessons from latest heparin fatality 
•  "4" or "units" confusion leads to fatality
• Parental dosing study

March 2010 (download) 

Topics include:

• Oral syringes ... again
• Multi-lumen catheter leads to drug mix up
• Safer connectors in UK
• Lithium safety alert
• iPhone app for ISMP alerts and reporting!
• Liquid medications: order by metric weight - not volume
• National alert system for very serious drug errors to start in US
• When an allergy is not an allergy
• FentaNYL patch serious adverse events increasing
• H1N1 infuenza - is it covered by the seasonal influenza vaccine?
• Reminder about 10-fold dosing errors
• Insulin infusion mix up
• Drug mix up - levetiracetam and levocarnitine

December 2009 (download) 

Topics include:

• Concerns about Jurnista (hydromorphone) tablets.
• Definition of 'near miss'
• Caution urged with weekly dosing of thyroxine
• Pharmaceutical companies can help reduce 10-fold overdose errors
• Safe post-op monitoring after opioid administration
• Oral syringes - some hospitals still don't use them despite the risks of using parenteral syringes
• Insulin cartridges are not mini-vials
• Don't be a borrower or lender!
• Kids harmed by hypotonic IV fluids

September 2009 (download) 

Topics include:

• Label oral liquid pharmaceuticals with volume (mL) and weight (mg) of dose?
• Tamiflu - another oral syringe safety concern
• Look-alike or sound-alike drug name lists
• Hydromorphone overdose
• Volume control sets - drug incompatibility and concentrated infusion concerns
• Intrathecal injections warrant a mask being worn
• Smoking cessation drugs - new warnings
• Insulin errors
• Handwriting confusion - Provera, Prozac or Proscar?
• Fatal confusion - naloxone/Lanoxin
• Always query unusual doses
• Fatality from intravenous administration of milk to premature baby

June 2009 (download) 

Topics include:

• Route of administration - confusion due to packaging
• Illegal prescriptions
• Dose errors with acetylcysteine (Mucomyst) ampoules
• Potential hazards associated with colour-coded syringes for anaesthetic drugs
• Text messaging abbreviations creeping into medication orders!
• Inattentional blindness: what captures your attention?
• Insulin pens and cartridges are for individual patient use only
• Methotrexate overdose
• Criminalisation of human errors in health care

March 2009 (download)

Topics include:

• Revatio = sildenafil = Viagra
• Mobile phones and email could prevent harm
• Lyrica-Lopressor mix-up
• U looks like 4 - leads to insulin overdose
• USP's safe practice environment chapter
• Cotrimoxazole-induced hyperkalaemia
• Alcohol abuse and hand sanitisers
• Misprogramming PCA concentration leads to dosing errors
• Near-miss involving cyclophosphamide