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Volume 4, Issue 1 UPDATE-ERR™ Winter 2011
News from ISMP

Many pharmacies use sig (or speed) codes and mnemonics to ease and accelerate the data entry process. Sig codes are programmed into the pharmacy computer system and used to represent a specific set of directions. For example, a computer system could be programmed so that the sig code “1TBID” will produce “Take 1 tablet by mouth twice daily” on the pharmacy label. Mnemonics on the other hand are programmed to represent a specific drug and dosage strength combination. For example, “LIP20” could be used to represent Lipitor 20 mg. While these codes can save time, they are not without risk. In our December 2004 issue, we discussed how a non-specific mnemonic contributed to a mix-up between metroNIDAZOLE and metFORMIN. Below is an example reported to the ISMP Medication Errors Reporting Program that illustrate how processes involving sig codes can contribute to
medication errors.

We learned that the directions for the oral contraceptive TRISPRINTEC (ethinyl estradiol and norgestimate) were entered incorrectly. The directions should have been “Take 1 tablet daily for dysmenorrhea,” but instead the prescription was labeled “Take 1 tablet daily for dyspepsia.” Upon investigation, the pharmacy discovered that the sig code “dys” had been created as a short cut for dyspepsia. However, the technician believed it to represent dysmenorrhea. The technician entered “dys” during data entry and the translation to dyspepsia was not caught by the verification pharmacist nor was it caught during two subsequent refills. The reporter suggested a contributing factor may have been the ‘newness’ of the technician, but at ISMP, we feel the process of adding ambiguous, dangerous sig codes to computer systems, at store level, was also a contributing factor.

 

(excerpted from ISMP Medication Safety Alert!
Community/Ambulatory Edition December 2010

President's Message

Happy New Year to all of our Friends and Clients!

Med-ERRS had a busy 2010, and is looking forward to working with all of you in 2011.

We have added several options to the services that we offer through our trademark safety testing portfolio. These improvements have evolved based on your needs as well as discussions with the FDA related to our collaboration with a sponsor on the PDUFA IV Pilot Project. While there has not been the response by sponsors to this program that the FDA had hoped for, we had the opportunity to participate in two Pilot Projects, and this has provided us with great insight into what the FDA will expect in the future.

We welcome the opportunity to describe these additions to our process on an individual basis and can work collaboratively with you on tailoring our trademark safety testing services to fit your needs. Please contact us for more information.

Med-ERRS also will be launching our new website in the coming weeks, so stay tuned for an announcement. We hope it will be informational and easy to navigate!

Best wishes for a prosperous 2011,
Susan

In the News

Drug Approvals Down in 2010
http://online.wsj.com/article/SB10001424052748704543004576052170335871018.html

Why are X and Z So Popular in Drug Names?
http://www.bmj.com/content/341/bmj.c6895.full

Links from ISMP Newsletter

ISMP Updates its List of Drug Name Pairs with TALL Man Letters

 

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Med-ERRS Services

  • Trademark Evaluation: Med-ERRS has developed a service for evaluating the safety of trademarks called the ERRS MODELTM, which incorporates various techniques recommended by the FDA to evaluate the safety of trademarks.
  • SCREEN-ERR: Helps companies evaluate multiple pharmaceutical trademark candidates at an early stage in the trademark development process.
  • Package and Label Evaluation: Helps clients create packaging and labels that are easy to understand and consistent with the most current FDA and world wide regulatory authorities.
  • Safety Consulting: Provides consultative services which are related to a variety of medication safety-related issues. 
  • EVALUATE-ERR: Conducts an in-depth analysis of error reports using data from the client as well as other medication error databases.


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