ISMP was shocked and saddened to learn the Tennessee Board of Nursing recently revoked the license of a nurse involved in a fatal medication error. This week’s ISMP free newsletter featured article presents an analysis of the process leading to the Board’s decision and calls for better ways to achieve justice, learning and improvement in patient safety: https://www.ismp.org/node/26713
MSOS News
Time is running out to register for ISMP's next virtual Practitioner in Residence (PIR) program on August 23-27, 2021! Benefit from an individualized development program that fosters practical ideas for organizational process and culture change; it’s a cost- and time-effective way to help solve challenges and advance your career. Participants are encouraged to bring their current medication safety issues to discuss and learn directly from nationally-recognized experts.
To learn more and to enroll, visit: https://www.ismp.org/node/25363
Read this week’s ISMP newsletter free featured article for analysis of a recently reported error where a postcraniotomy patient received contrast media via an external ventricular drain instead of an appropriate IV route during an MRI study. The article includes recommended safety steps to prevent similar errors: https://www.ismp.org/node/26401
Sign up now for the next MSOS Member Briefing webinar scheduled to be held on Thursday, July 22, 2021 from 1:00-2:00 PM ET. Register Now: https://ecri.zoom.us/webinar/register/WN_s6FpmZc2Ss6AoIIObhqrcA Short medication safety-related presentations for this webinar will include:
• Use of kits for immediate use infusions Joel Daniel PharmD, MS, CPPS Medication Safety Pharmacist Cox Health
• Specialty Pharmacy Medication Safety Challenges Jill Paslier, PharmD, CSP, FISMP Specialty Pharmacy Consultant and ISMP International Medication Safety Management Fellow
•Parenteral Nutrition Safety Issues Joe Boullata, PharmD, RPh, CNS-S, FASPEN, FACN Pharmacy Specialist Clinical Nutrition Services Hospital of the University of Pennsylvania
Read this week’s newsletter free featured article on the need to adopt dihydropyrimidine dehydrogenase (DPD) enzyme deficiency screening before the administration of fluoropyrimidine chemotherapy. The article argues that although the incidence is relatively low, patients who have it are unable to metabolize these drugs and can suffer severe toxicity and even fatal adverse reactions: https://www.ismp.org/node/25779