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PBM-MAP-VPE Ez-Minutes Newsletter is an on-line quarterly newsletter. For the newsletter to automatically be delivered to your InBox, you need to subscribe to it. The purpose of the PBM-MAP-VPE Ez-Minutes is to communicate with the field on items that will impact clinical practice in the VHA…whether it is changes to the National Formulary, availability of new Criteria for Use, or urgent medication safety issues. Our goal is to keep front line clinicians/providers and supporting staff informed while serving our Nation’s Veterans. How do I subscribe? Glad you asked. For NEW subscribers only; click on stxcollage@va.gov with "PBM subscribe" in the subject line to subscribe to the newsletter. It is easy, and FREE! For “old” subscribers, (but young at heart), please forward this newsletter to your medical staff, fellow colleagues, and P&T members, so they too may take this opportunity to become better informed.
Editor's Note: The newsletter is in a HTML format. A printer-friendly document throughout the system is more likely to occur with a HTML format compared to a word document. Users should select print preview and review the document, then make any necessary changes to the document before printing to ensure the document will print fine for their hardware configuration. Any feedback and comments are welcomed. Send comments directly to Janet.Dailey@va.gov with Ez-Minutes in the subject line. Look for the next issue of the newsletter on August 9, 2011 |
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· National PBM Documents Posted: February-April, 2011)
· VAMedSAFE Documents Posted (February-April, 2011)
· Look Alike Sound Alike Drugs
· Pharmacy-Prosthetics-SPD Logistics Workgroup Recommendations
· VHA and DSB: Recent Board Topics
· Q&A and Useful Links to Field FAQs
· CEUs: PBM-MAP-VPE Educational Programs
· Publications by VA Pharmacists
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National PBM Communication · *Abbott Glucose Test Strips Recall [January, 2011] · Albuterol Sulfate Inhalation Solution Recall- Packaging Error [February, 2011] · Citalopram and Finasteride Recall Due to Mislabeling [March, 2011] · Dexamethasone Sodium Phosphate Inj USP 4mg/ml and Particulate Formation Recall [March, 2011] · Maternal and Newborn Risks with Certain Medications Used During Pregnancy [March, 2011] · Povidine® Iodine Prep Pads and Potential Microbial Contamination Recall [March, 2011] · PPIs: Long-Term Use and Risk of Hypomagnesemia [March, 2011] · *Triad Group Recall-Sterile Lubricating Jelly and Alcohol Swab (December, 2010] *Posted after last issue of Ez-Minutes (Nov 2010-Jan 2011) was released.
National PBM Bulletin · Dicyclomine and Doxycycline LASA Confusion [March, 2011]
Please Note: On the Bulletins and New Alerts section of the VAMedSAFE website, click on the heading of the first column (Safety Issues) to sort Bulletins Communications alphabetically according to drug or safety issues, click on the heading of the second column (Date) to sort chronologically. |
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Look-alike Sound-alike (LASA) Drug Names Similar drug names account for approximately 15% of all reports to the USP Medication Errors Reporting program.1 VAMedSAFE receives voluntary reports of LASA incidents from the field and disseminates the information via a PBM Safety Bulletin if deemed necessary. Each year, from a system-wide perspective, VAMedSAFE queries VISN Pharmacy Executives on reports of LASA close-calls and mix-ups. Below are the results of the query from 2010.
A cumulative VA LASA list can be found at: http://www.pbm.va.gov/vamedsafe/Cumulative%20VA%20LASA%20list.pdf. Additionally, LASA anecdotal reports are submitted to the Institute for Safe Medication Practices (ISMP) Newsletter. A compiled list form 2010 reported LASA in ISMP newsletters can be found at http://www.pbm.va.gov/vamedsafe/Reported%20LASAs%20in%20ISMP_2010.pdf
In 2010, the JCAHO LASA requirement (NPSG.02.02.01) was moved to the Medication Management Standard MM.01.02.01. Element of Performance #1 for the Medication Management Standard reads: “The hospital develops a list of look-alike/sound-alike medications it stores, dispenses, or administers. Note: One source of look-alike/sound-alike medication is The Institute for Safe Medication Practices. http://www.ismp.org/Tools/confuseddrugnames.pdf.” Furthermore, Elements of Performance #2 and #3 states that the hospital takes action to prevent errors involving the interchange of the medications on its list of LASA medications, annually reviews and, as necessary, revises its list of look-alike/sound-alike medications.
To report LASA close calls and mix-ups for 2011, please email Muriel.Burk@.va.gov with details pertaining to the cases and any follow-up actions taken.
Reference: 1. USP Quality Review. March 2001. No. 76 Submitted by Muriel Burk, PharmD, VAMedSAFE Pharmacy-Prosthetics-SPD (PPSPD) Workgroup Recommendations The Pharmacy, Prosthetics, SPD workgroup was created to help clarify the responsibility for management (e.g., ordering, storing, purchasing, and dispensing) of those products in which it is not clear which service should provide. The workgroup is NOT responsible for determining formulary status, clinical merit or appropriate use of the products reviewed. Implementation of these recommendations should be coordinated between services at local sties. The table below depicts the various products reviewed at the December 2011 meetings. The X marks which service(s) is responsible for managing the respective products Please Click Here for further details and explanation of the decision process including decisions made from earlier meetings.
*In cases of medical necessity only. A form must be completed and approved before the product is supplied. Note: The review process takes approximately 10 days. +Specialized pillboxes are those that are requested by a provider for a patient who may have certain circumstances in which the “standard” pillbox used by the medical center does not meet their needs. Standard pillboxes (listed in last issue of Ez-Minutes Nov 2010-Jan 2011) are those that are purchased and used in the medical center and meet the needs of the majority of the patients. The Veteran’s Health Administration (VHA) and FDA’s Drug Safety Oversight Board (DSB) The FDA Drug Safety Oversight Board (DSB) discussed seven topics during the monthly meetings between January-March 2011. A link to the Public Summary of each meeting is included. The DSB members representing the VHA include Drs. C. Bernie Good (VA Pittsburgh Healthcare System), Peter Glassman (VA Greater Los Angeles Healthcare System), Walid F. Gellad (VA Pittsburgh Healthcare System), Mark Enderle (VA Arkansas Healthcare System), and William Duncan (VA Washington DC Healthcare System). The Board also discussed recently released and proposed Drug Safety Communications at each of its meetings. FDA Drug Safety Communications can be accessed through the following webpage: http://www.fda.gov/Drugs/DrugSafety/ucm199082.htm
Update on Recent Board Topics: January 2011: Update on Operating Room Fires and Alcohol-Based Skin Preparations, Safe Injection Practices and Vial Fill Issues, a draft Drug Safety Communication involving over the counter monograph products and related (unapproved) prescription products used as topical anesthetics. http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm243406.htm February 2011: Glass Lamellae in Parenteral Drug Products, Update on Communicating Drug Safety Information. http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm247599.htm March 2011: Update on Stimulant Drugs Used to Treat Attention Deficit Hyperactivity Disorder (ADHD), Update on Systems Biology Modeling and Drug Safety. http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm251555.htm
Editor’s Note: As mentioned previously, a new feature to the newsletter is including recent updates discussed by the DSB. We hope that it will provide greater awareness among VA Healthcare professionals about the DSB. If you have any feedback to the DSB, please contact Steven Osborne, MD, Executive Director of the Drug Safety Oversight Board. If you are eager to know the status of a new drug as it moves through the formulary approval process or have a question about criteria for use etc., drop us an e-mail at VHAPBH Ask PBM Clinical (AskPBMClinical@va.gov). Please note this address should only be used by VA employees; requests from e-mail addresses outside the VA may not receive a response. Helpful Links for Frequently Asked Field Questions: CLICK HERE Accredited PBM-MAP-VPE Educational Programs
*Per Field Request: Posted on the PBM website (Under Distance Learning Broadcast and other Educational Opportunities tab) are screen shots for each respective program. To date, since these programs can only be taken once, the content is being provided to the field to modify or use for future use if needed. An update on whether these programs will be “reset” will be posted later. However, if LMS/EES elects to reset the programs, NO accreditation will be provided. Please note the determination of participants for which programs to view (if used) is by the discretion of local facility and/or VISNs. These programs are not mandatory. In the past, facilities have assigned these as mandatory programs for all staff. Medical Centers should also consider using the results of anticoagulation quality assurance and performance improvement activities in determining educational needs to improve staff competence. Contact Janet Dailey Janet.Dailey@va.gov with any questions or additional information. Click HERE and open the Distance Learning Broadcast folder for more program details. Publications by VA Pharmacists: Great submissions! This section will be moving to a new SharePoint site soon. Stay tuned for further details in the next issue of Ez-Minutes. Clinical Pharmacy Practice Site: Bookmark this site for information about the upcoming Clinical Pharmacy Boot Camps and other helpful resources. |
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