Voice of the Diabetic

Voice of the Diabetic

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MEDICATION ERRORS

ISMP MEDICATION SAFETY ALERT, the newsletter of the Institute for Safe Medication

Practices (ISMP), warns health professionals that poorly written orders for

the oral diabetes medication Avandia (rosiglitazone) can look like Coumadin

(warfarin). Both drugs are available in 4mg oral tablets, increasing the likelihood

of a mix-up.

The newsletter reports of specific mix-ups, and details one case where the

pharmacist first misread the prescription, and then, inspecting the document,

realized Coumadin would be inappropriate to this patient. As misdosage with

either medication could cause grave danger to a patient, ISMP suggests that

all prescription orders should include the medication's purpose. Also, nurses

and pharmacists must clarify the drug's purpose prior to dispensing the medication.

For further information, contact: ISMP, telephone: 1- 800-324-5723; e-mail:

[email protected]

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