This is by no means the first time that an NMBA has caused a fatal error—the Institute for Safe Medication Practices (ISMP) has been reporting on them since the 1990s (sidebar). These repeated tragedies show that “directors of pharmacy have been hitting the snooze button on this for at least 25 years,” said Jeffrey Norenberg, PharmD, PhD, the director of the radiopharmaceutical sciences program in the College of Pharmacy at the University of New Mexico Health Sciences Center, in Albuquerque. “Departments of pharmacy are culpable in ignoring the mandate from the Joint Commission, which requires prospective medication order review by a pharmacist and that formulary controls are in place for all drugs used in radiology.”
