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Am Fam Physician. 2002;65(11):2384-2389

Potential for Medication Errors in Hospitals

The Institute for Safe Medication Practices (ISMP) reports that while the number of hospital medications packaged in unit-dose form has decreased over the past five years, the potential for medication errors has increased.

According to the ISMP, the use of bar-coded unit packages in hospitals is an important step in preventing medication errors. A recent ISMP survey found that almost one half of respondents indicated they are presently engaged in discussing possible implementation of bar-code technology or have partially implemented this technology in their hospitals. After initial concerns about the cost of implementing this type of system, 84 percent of respondents said that this would not deter them from purchasing a specific vendor’s unit dose medication with a bar code.

The ISMP stresses that errors are less likely to occur when the medication and dosage can be checked with the swipe of a bar-code reader. About 72 percent of those surveyed reported having a problem with medications that were previously provided by the manufacturer in unit-dose packaging but are no longer available in this form. Also, 73 percent of respondents reported the same problems with newly marketed medications, especially those that have been available for less than 18 months.

Medications that are not sold in unit-dose packages must be repackaged by hospitals, and this is the point at which problems sometimes occur. Survey respondents estimated that repackaging medications can lead to an error rate as high as 10 percent.

For more information on this and other medication safety issues, visit the ISMP Web site

Infliximab for the Treatment of Rheumatoid Arthritis

The U.S. Food and Drug Administration has approved infliximab (Remicade), in combination with methotrexate, to improve physical function in patients with rheumatoid arthritis. The combination also inhibits the progression of structural damage and reduces the signs and symptoms in patients with moderate to severe active rheumatoid arthritis who have not responded to treatment with methotrexate alone.

The manufacturer of infliximab reports that more than 2 million persons in the United States have rheumatoid arthritis. This disease can interfere with even the simplest of daily activities, such as getting out of bed, bathing, buttoning a shirt, and walking up stairs. According to guidelines for the management of rheumatoid arthritis from the American College of Rheumatology, the ultimate goal of therapy is to stop progression of the disease and enable patients to return to normal activity.

In clinical trials, patients who used infliximab with methotrexate had significant improvement in symptoms compared with patients taking methotrexate alone. The improvement was evident after 54 weeks of treatment and was sustained through 102 weeks.

Patients who have been exposed to tuberculosis should be tested before taking infliximab. Patients with infections, multiple sclerosis, or exposure to histoplasmosis should also be identified before using infliximab. Other side effects of infliximab therapy include hives, difficulty breathing, low blood pressure, upper respiratory infections, headache, cough, sinusitis, or rash.

More information is available online or by calling the manufacturer at 800-683-7401.

Evaluation and Management of ‘Incidentalomas’

A consensus panel assembled by the National Institutes of Health (NIH) has issued recommendations to aid physicians in evaluating a particular class of tumors of the adrenal glands and determining which should be removed and which should be left alone. The tumors are called “incidentalomas” because they are discovered by chance while testing the patient for other conditions. Before the new imaging technologies were available, these types of tumors usually went undetected.

Based on an examination of the latest research, a review of the literature, and a systematic review of the available evidence, the consensus panel has made the following recommendations.

  • One type of adrenal tumor, pheochromocytoma, releases hormones that can cause dangerously high blood pressure. Another type, called an adrenal cortical cancer, has a high rate of mortality. When technically possible, these types of tumors should be surgically removed, regardless of size.

  • Incidentalomas should be surgically removed if they are larger than 6 cm, and those smaller than 4 cm should be watched for growth or symptoms. When tumors are between 4 cm and 6 cm, decisions on whether to remove these tumors should be based on other factors, such as whether the tumor is producing abnormal levels of hormones.

  • Minimally invasive laparoscopic surgery is an appropriate option for removing smaller noncancerous tumors. Open surgery involving a relatively long incision is usually appropriate for removing malignant tumors or large benign tumors.

  • Because management of incidentalomas may involve complex decisions, patients should be treated by a team of physicians with expertise in endocrinology, radiology, surgery, and pathology.

  • Because there are important gaps in knowledge about incidentalomas, more research should be conducted on the physical and mental health outcomes and quality of life of patients whose tumors have not been removed.

A full text copy of the NIH statement can be accessed online at or by calling 888-NIH-CONSENSUS (888-644-2667). A summary of the evidence report is available from the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse by calling 800-358-9295 or by visiting the AHRQ Web site

Use of Endoscopic Retrograde Cholangiopancreatography

A consensus panel assembled by the National Institutes of Health (NIH) has issued recommendations on the use of endoscopic retrograde cholangiopancreatography (ERCP). According to the consensus panel, ERCP is becoming a therapeutic rather than diagnostic tool. The consensus panel predicts that less-invasive imaging techniques will soon replace the value of ERCP in diagnosing pancreaticobiliary diseases, but ERCP is still very useful in treating benign and malignant diseases of the pancreas and biliary tract.

Based on evaluation of the latest research, a review of the literature, and a systematic review of the available evidence, the consensus panel has made the following recommendations.

  • Evidence supports the use of ERCP in treating several conditions, including symptomatic gallstone disease, common bile duct stones, recurrent pancreatitis, and pancreatic pseudocysts. ERCP with endoscopic sphincterotomy and stone removal is useful for patients with jaundice caused by stones in the common bile duct, dilated common bile duct, cholangitis, or acute pancreatitis. The role of ERCP is unclear in the evaluation or management of abdominal pain without specific anatomic or biochemical abnormalities referable to the common bile duct or pancreas.

  • ERCP is still the best way to diagnose suspected ampullary cancers and for patients with pancreatic or biliary cancer who are not candidates for surgery.

  • While ERCP has therapeutic potential, physicians should be aware of the potential for substantial risks. Appropriate training and expertise are necessary, especially for advanced ERCP; avoiding unnecessary ERCP is the best way to reduce complications such as post-procedure pancreatitis.

The full text of the NIH consensus statement is available by calling 888-NIH-CONSENSUS (888-644-2667) or online at A summary of the evidence report may be obtained by calling the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse at 800-358-9295 or visiting the AHRQ Web site

FDA Approves Surgical Device to Treat Farsightedness

The U.S. Food and Drug Administration (FDA) recently approved a new surgical device for the treatment of farsightedness. Conductive keratoplasty uses heat-causing radiofrequency waves that pass through a probe the size of a human hair to reshape the flattened cornea.

Conductive keratoplasty is reported to be less invasive than laser surgery. However, the FDA stresses that the vision correction may be temporary, because vision can deteriorate for at least a year after surgery. According to the FDA, some visual regression is expected after any correction of far-sightedness, but while the vision of patients who have had laser surgery usually stabilizes after three to six months, patients who choose conductive keratoplasty often lose, on average, another 11 percent of their vision in the year after surgery. Also, available data have not shown whether retreatment is safe or effective.

CFH/FDA Educational Campaign on Pregnancy and the Use of Medication and Supplements

Because prescription and nonprescription medications and dietary supplements can be passed from a mother to her unborn child and can pass through breast milk, it is important that women are made aware that what is safe for them may not be safe for their infant. To accomplish this, the Council on Family Health (CFH) and the U.S. Food and Drug Administration (FDA) have collaborated on a national campaign to teach women about the safe use of medication and dietary supplements before, during, and after pregnancy.

The CFH/FDA campaign urges pregnant and breastfeeding women to discuss the use of any medications with their physician. The CFH also offers the following advice:

  • When pregnant or breastfeeding women are given permission to use a nonprescription medication, they should always remember to read the label and pay attention to usage directions and warnings. Any questions about the medication should be directed to their physician, pharmacist, or another health care professional.

  • Pregnant women should go to all prenatal check-ups.

  • Women should remain in close contact with their physician throughout pregnancy and while breastfeeding.

The CFH/FDA campaign involves television, radio, and print public service announcements. A tip sheet, called “New Moms and Moms-to-Be: Someone Is Counting on You,” is available in English and Spanish. The tip sheet is available free of charge by sending a self-addressed, stamped envelope to the Council on Family Health, “Someone Is Counting on You,” 1150 Connecticut Ave., NW, Suite 1200-B, Washington, DC 20036, or by visiting the CFH Web site The CFH is also working with several pharmacy chains to distribute this information to the public.

Frown Lines Reduced with Botulinum Toxin Injection

The U.S. Food and Drug Administration (FDA) recently approved botulinum toxin type A (Botox Cosmetic) for the treatment of moderate to severe frown lines between the eyebrows. Botulinum toxin type A smooths facial lines by paralyzing or weakening the muscles that cause frowning. In clinical trials, the severity of frown lines was reduced for up to 120 days. The FDA recommends using the lowest effective dosage and limiting treatments to once every three months.

According to the manufacturer, botulinum toxin type A is currently approved by the FDA to treat patients with crossed eyes, uncontrollable blinking, and cervical dystonia, in addition to this newest indication.

NCI Report on Adolescent Smoking Prevalence

In a recent report on adolescent smoking, the National Cancer Institute (NCI) concluded that increases in cigarette taxes and comprehensive tobacco prevention programs have been effective in reducing the number of young persons who smoke.

The NCI study examined research on adolescent smoking behavior from the early to middle 1990s in California, Massachusetts, and Florida. Researchers found that comprehensive state tobacco prevention programs were successful at preventing children from smoking at a time when national rates were skyrocketing. They also found that increases in cigarette taxes prevent children from starting to smoke and get current young smokers to quit. According to the study, tobacco prevention programs have dramatically reduced smoking rates, saved lives by decreasing the rate of lung cancer and heart disease, and saved millions of dollars in smoking-related health care costs.

“Monograph 14: Changing Adolescent Smoking Prevalence: Where It Is and Why” may be accessed online More information on the benefits of cigarette tax increases ( and comprehensive tobacco prevention programs ( is also available online.

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Copyright © 2002 by the American Academy of Family Physicians.

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