Hospital Pharmacy - November 2011 - (Page 830)

Hosp Pharm 2011;46(11):830–834 2011 Ó Thomas Land Publishers, Inc. www.thomasland.com doi: 10.1310/hpj4611-830 ISMP Medication Error Report Analysis Oral Solid Medication Appearance Should Play a Greater Role in Medication Error Prevention Some Nurses Unaware of Proper Use of Sensorcaine Vials Tall Man Letters in RxNorm Tamiflu Concentration Change Michael R. Cohen, RPh, MS, ScD,p and Judy L. Smetzer, RN, BSN† These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers’ names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the conﬁdentiality and security of the information received and respects reporters’ wishes as to the level of detail included in publications. ORAL SOLID MEDICATION APPEARANCE SHOULD PLAY A GREATER ROLE IN MEDICATION ERROR PREVENTION Generic products are widely dispensed in US hospitals and ambulatory pharmacies as a cost-effective substitute for brand-name medications. According to the Generic Pharmaceutical Association, generic medications are dispensed for 69% of all ambulatory prescription medications but account for only 16% of the total costs of all dispensed prescription drugs.1 While generic medications have been approved by the US Food and Drug Administration (FDA) as bioequivalent to their associated brand-name medications, oral generic medications often look substantially different than their brand-name counterparts and other generic versions of the same medications. Thus, consumers can receive different looking tablets or capsules every time they reﬁll their prescription if generic products are dispensed. For example, Prozac (ﬂuoxetine) has 10 different generic bioequivalent products, but each is different in appearance.2 Manufacturers of generic drugs design their product’s appearance, making no effort to ensure it looks like other generics or the brandname product, primarily to avoid litigation with brandname manufacturers that claim intellectual rights to the appearance of their products.3 Risks When Generics Dont Look Like the Brand Patients and many health care practitioners have learned to rely on the color, size, and shape of oral solid medications as one—but hopefully not the only—way *President, Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044; phone: 215-947-7797; fax: 215-914-1492; e-mail: mcohen@ismp.org; Web site: www.ismp.org. †Vice President, Institute for Safe Medication Practices, Horsham, Pennsylvania. 830 Volume 46, November 2011 http://www.thomasland.com http://www.ismp.org http://www.ismp.org

Table of Contents for the Digital Edition of Hospital Pharmacy - November 2011

Hospital Pharmacy - November 2011
Contents
Editorial
ISMP Medication Error Report Analysis
ISMP Adverse Drug Reactions
Cancer Chemotherapy Update
Off-Label Drug Uses
RxLegal
Original Articles
Formulary Drug Reviews
Current FDA-Related Drug Information
Pharmacy Automation and Technology
Director’s Forum
Hospital Pharmacy Pulse
Index to Advertisers

Hospital Pharmacy - November 2011