ISMP Warning on Heparin/Hespan Mix-ups

The Institute for Safe Medication Practices (ISMP) has issued a Medication Safety Alert on mix-ups of Hespan and heparin. In two 1998 issues of the safety alert, the ISMP cautioned medical institutions about reported mix-ups between the two medications. The errors are thought to be caused in part by similar characters (“h-e,” “p-a” and “n”) in the drug names that appear in the same order. Hespan products may be packaged in premixed bags with coloring similar to that of bags containing heparin, and they may be stored near one another because of the similar spelling.

In some cases, reports the ISMP, nurses have retrieved heparin from an automated dispensing cabinet in which heparin and Hespan were stored and where both names appeared as choices on the machine's computer screen. Because Hespan, a plasma expander, is sometimes used in patients who are actively bleeding, the danger of administering heparin in error is obvious.

In the past few years, the ISMP has communicated with the manufacturer of Hespan and the U.S. Food and Drug Administration about this problem. The appearance of the heparin container changed in 1995, but mix-ups continue to be a problem. The ISMP strongly encourages use of the generic name, hetastarch, when prescribing Hespan, when processing the order, on computer and automated dispensing equipment inventory screens, and on preprinted order forms. Physicians might also consider using an alternate hetastarch product. If physicians choose to maintain supplies of Hespan and heparin solutions in premixed form, the ISMP recommends labeling both products, their storage bins and automated dispensing cabinet pockets with auxiliary labels before placing products in inventory.

For more information on the ISMP, visit the ISMP Web site at http://www.ismp.org or call 215-947-7797.

Increase in Vaccination Coverage Levels

Sustained high vaccination coverage levels in the United States are needed to decrease the rates of vaccine-preventable diseases. According to a report in the September 24, 1999 issue of Morbidity and Mortality Weekly Report, an important component of the U.S. vaccination program is the assessment of vaccination coverage.

To assist in this assessment, the Childhood Immunization Initiative (CII) was begun in 1993 to increase levels of vaccination coverage among children during the first two years of life to a minimum of 90 percent by 1996 for universally recommended childhood vaccinations and to monitor trends in vaccination coverage. Vaccination objectives were also included in the national health objectives for 2000 initiative.

Except for hepatitis B vaccine, the 90 percent coverage goals were achieved and maintained through implementation of the CII by public-and private-sector organizations and health care professionals at the national, state and local levels.

National vaccination coverage achieved was a minimum of 90 percent each for three doses of polio-virus vaccine, three doses of Haemophilus influenzae type b vaccine and one dose of measles-containing vaccine. Coverage with four doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids and three doses of hepatitis B vaccine was the highest ever reported (84 and 87 percent, respectively). Varicella vaccine, which was first recommended for use in 1996, also had the highest coverage ever reported (43.2 percent).

Therapies for the Prevention of Breast Cancer

The Health Technology Advisory Committee (HTAC) has published a report on preventive therapies for women at increased risk for breast cancer. HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The report evaluates data on the efficacy, safety and quality-of-life outcomes of preventive mastectomy for breast cancer. It also summarizes findings of the American Society of Clinical Oncology in their assessment of tamoxifen citrate (Nolvadex) and raloxifene hydrochloride (Evista). The assessment only refers to breast cancer in women.

HTAC reports that no therapy can prevent breast cancer with absolute certainty. Preventive mastectomy and drug therapies may reduce the risk of breast cancer in selected women who are at high risk for breast cancer.

HTAC makes the following recommendations:

• Physicians should continue to stress the importance of regular clinical breast examinations and mammography (appropriate to age and risk status) as well as breast self-examination to all women in their care.

• Before starting preventive therapy, women must consider the benefits and risks of treatment, including their risk for breast cancer and their susceptibility to potential side effects.

• Women should be informed about the efficacy of treatments, their potential risks and effects on quality of life, uncertainties in breast cancer risk estimates, the limitations and implications of genetic testing, insurance issues and costs of the procedures or drug regimens.

• Additional data should be collected to determine the optimal roles of surgical and chemopreventive treatment for prevention of breast cancer in women at increased risk.

• Additional research should be performed to find methods for early detection of breast cancer, and to determine breast cancer risks and the clinical course of the disease in women with a strong family history, genetic susceptibility or other risk factors.

This report (document no. 990901) and others published by HTAC may be obtained free of charge by calling 651-282-6374 or by e-mail: htac@health.state.mn.us. All reports are also available on the HTAC Web site (http://www.health.state.mn.us/htac/index./htm).

Office Spirometry for the Detection of COPD

The National Lung Health Education Program (NLHEP) has released a consensus statement calling for more widespread use of office spirometry for the early detection of chronic obstructive pulmonary disease (COPD) in its most treatable stage. The statement was based on conferences sponsored by the American College of Chest Physicians and the National Heart, Lung, and Blood Institute of the National Institutes of Health and reflects findings of the conference participants. The statement appears in the April 2000 issue of Chest.

COPD is a serious form of lung disease and the fourth leading cause of death in the United States. COPD usually occurs in current and former smokers, but can also be found in persons who are exposed to occupational dust, environmental tobacco smoke, air pollution or in persons who have a relatively rare genetic disease, alpha₁-antitrypsin deficiency.

While diagnostic-quality spirometry may be used to detect COPD, NLHEP recommends the use of the newer office spirometers for the following reasons: they are less expensive, smaller in size, require less effort to perform the test, have improved ease of calibration and have an improved quality assurance program.

The statement recommends that primary care physicians perform office spirometry on all patients 45 years or older who smoke. When discussing the spirometry results with smokers, physicians should give strong advice to quit smoking and refer patients to local smoking cessation resources. The statement also recommends that office spirometry be used for patients with respiratory symptoms such as chronic cough, sputum production, wheezing or dyspnea on exertion to detect COPD or asthma.

While the NLHEP advocates use of office spirometry for early lung health assessment, the statement emphasizes that it should not be used for diagnostic testing, surveillance for occupational lung disease, disability evaluations or research purposes. Diagnostic spirometry would be the appropriate tool in these cases.

Recommendations for Children with Autism

Thousands of children with autism may go undiagnosed, according to a national panel of researchers who have compiled new recommendations for the American Academy of Neurology and the Child Neurology Society. Because of these missed diagnoses, the panel recommends that family physicians begin looking for autism early in infancy so that treatment can begin before the disease becomes severely debilitating. The recommendations appear in the December 1999 issue of the Journal of Autism and Developmental Disorders.

The recommendations are based on a review of current research and back formal standards expected to be set by the associations next year.

The new recommendations include the following:

• Starting in infancy, every wellness visit to the physician should include developmental screening for autism. The researchers also recommend that professionals involved in early child care should be taught to recognize the early signs of the disorder so that children at risk can be treated as early as possible.

• Early-childhood workers, including school and day care personnel, should look for signs of autistic behavior and also for learning problems, delays in language ability, and anxiety or depression, all of which may be signs of autism.

• Health care and school personnel should talk with families about autism to get information about the child's behavior at home and to keep them informed about treatment options.

• Workers in education should screen older children with mild symptoms of autism in classrooms and recreational settings such as playgrounds. In such settings, behavioral difficulties may be more apparent than in a physician's office or at home.

• Physicians should dedicate more time to screening young patients whom they suspect of having autism. A thorough neurologic, hearing and speech examination should be done before making the diagnosis.

• Further research should be conducted to develop screening tools for infants and to explore the roles of brain activity, genetics and family environment in the development of autism.