ISMP Quarterly Action Agenda: July - September 2002

From the October 3, 2002 issue

One of the most important ways to prevent medication errors is to proactively seek and use knowledge from other organizations that already have experienced similar problems. To promote such a process, administrative staff and an interdisciplinary committee at each practice site should review the following material to prompt discussion and stimulate action to reduce the risk of errors. The following selected items appeared in the ISMP Medication Safety Alert! between April - June 2002. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information as desired. Many product-related problems can be visualized in the ISMP Medication Safety Alert! section. The American Society of Health Care Risk Management (ASHRM) routinely provides the ISMP Quarterly Action Agenda to all its members. ACPE credit is available for pharmacists (see www.ismp.org for details).

I. Problematic nomenclature, labeling, and packaging of products

• ZYVOX (linezolid) and ZOVIRAX (acyclovir) (17)
  Problem: Similar names and strengths contributed to a pharmacist misreading an order for Zyvox 600 mg BID as Zovirax 600 mg BID.
  Recommendation: Build alerts into pharmacy computer systems, use auxiliary labels on drug containers, and separate the storage of these products. Alert patients to the potential for a mix-up and encourage them to ask prescribers to list the drug's indications on all prescriptions.
• LUPRON DEPOT-PED (leuprolide acetate) and LUPRON DEPOT-3 MONTH (leuprolide acetate) (18)
  Problem: Confusion has occurred between these two products because they share the same 11.25 mg strength and are available in a kit with a pre-filled dual-chamber syringe.
  Recommendation: Label storage shelves to warn about dosage form mix-ups, build computerized warning messages, and use preprinted prescription blanks that clearly differentiate the products.
• trazodone and tramadol (14 , 19)
  Problem: A community pharmacist erroneously dispensed Purepac's trazodone 50 mg instead of tramadol 50 mg.
  Recommendation: Mark the containers to help differentiate the products and store them separately. In response to our request, FDA has sent letters to all manufacturers to ask them to use "tall man" lettering on container labels to help differentiate these two products.
• MYLOTARG (gemtuzumab ozogamicin) (19)
  Problem: The invoice labeling and wholesaler catalog information for Mylotarg states a "5 mg - 20 mL vial," while the package insert instructions specify a 5 mL volume after reconstitution.
  Recommendation: Place a message in the pharmacy computer system to alert staff.
• MIFEPREX (mifepristone) and CYTOTEC (misoprostol) (15)
  Problem: A prescription for mifepristone 200 mg PO daily was filled with misoprostol 200 mcg tablets. Similarity in the generic names, strengths (mg vs. mcg) and overlap of indication for use (early termination of pregnancy) led to the error.
  Recommendation: Prescribe these products using both the generic and brand name to avoid confusion.Problematic packaging of sample products (17)
  Problem: A patient instilled ELOCON (mometasone) 0.1% topical lotion into her eye because a sample bottle was packaged in a container similar to eye drops. Also, patients have taken 600 mg of CELEBREX (celecoxib) instead of 200 mg because the sample pack states "Celebrex 200 mg," but it actually contains three 200 mg capsules.
  Recommendation: Be alert to problematic packaging of sample products and review instructions for use with the patient.

II. Dangerous abbreviations, confusing dose designations, and unsafe ways of communicating orders

• Verbal order for "40 of K" (17)
  Problem: A physician who intended to prescribe 40 mEq of potassium chloride to be given IV over an hour instead gave a verbal order for
  "40 of K." The order was misunderstood and the patient received 40 mg of Vitamin K intravenously.
  Recommendation: Use full drug names, strengths, and routes of administration when prescribing. Require recipients of verbal orders to read back to the prescriber exactly what they transcribe. A pharmacist should screen orders for vitamin K before administration since it often suggests the occurrence of a warfarin overdose.
• Verbal order for gentamicin spells near disaster (18)
  Problem: A misheard verbal order for gentamicin 5 mg IV push resulted in a premature baby girl receiving gentamicin 500 mg IV push.
  Recommendation: When verbal orders cannot be avoided, pronounce the dose in single digits (five, zero, zero for 500). Also require prescribers to include the mg/kg dose and provide neonatal/pediatric units with a list of typical mg/kg doses for commonly used drugs.
• "Maximize" safety when titrating drug doses (19)
  Problem: Accepting orders for titration of pressor medications without a dose limit has led to severe peripheral effects and amputation. Unfortunately, many drug information resources do not offer much help because they do not specify a dose limit for titrated medications.
  Recommendation: Specify a dose limit for titrated medications at which the physician must be contacted. Have nurses assess peripheral circulation frequently to detect untoward effects as soon as possible.

III. Problems with drug information resources, patient education and monitoring, and medication storage

• Broselow Tape (16)
  Problem: The Broselow Tape for dosing drugs during pediatric emergencies uses some volumetric doses based on a specific strength. The wrong dose could be given because some drugs are available in several strengths.
  Recommendation: Ensure that drug concentrations in pediatric emergency drug supplies match those listed on the tape.
• Different dosage forms may not share the same monograph in the Physicians' Desk Reference (PDR) (16)
  Problem: A physician prescribed an erroneously high dose of IV acyclovir after inadvertently referring to an oral dosing table in the PDR. He didn't know that the PDR lists products separately by dosage form. Also, the PDR lists only products that manufacturers want to feature (not all products).
  Recommendation: Alert physicians to the format of drug information in the PDR. Consider providing a more comprehensive drug reference.
• Child overdoses on acetaminophen (16)
  Problem: A ten-year-old child died from acetaminophen toxicity. Accidental overdoses are related to differing concentrations between the infant's and children's formulations, the confusing way the drug concentration is listed on the bottle, inaccurate measurement when using a household teaspoon, and giving children multiple products that contain acetaminophen.
  Recommendation: Alert parents that the infant's drops are three times more potent than the children's liquid. Give parents written information on acetaminophen before leaving the hospital with their newborn. Stress that "more is not better," even with over-the-counter medications. Help parents recognize the seriousness of a dosing error and the need to call poison control for advice.
• Pain scales don't weigh every risk (15)
  Problem: A woman died from fentanyl toxicity after giving birth. Problems with pain management can be linked to insufficient patient monitoring and the vast array of analgesics prescribed for a patient with doses linked only to the patient's assessment of pain.
  Recommendation: Consider the patient's pain assessment, clinical observations, and monitoring parameters when selecting pain management therapy. Reduce the variety of analgesics prescribed to patients, eliminate orders with dosage ranges, and link specific dosages to the patient's response to therapy and clinical status, not to the patient's self assessment of pain alone.

IV. Other discussion items

• JC announces six new National Patient Safety Goals (15)
  Four of the six National Patient Safety Goals are related to medication safety: 1) improved patient identification processes; 2) improved verbal and written order communication; 3) standardization of concentrated electrolytes and their removal from patient care units; and 4) ensuring free-flow protection on all general-use and PCA pumps. Organizations will be expected to comply by January 2003.
• ISMP survey on pharmacy interventions (14)
  Over 600 pharmacists responded to a survey to tell us about: 1) factors that impede or facilitate pharmacy interventions; 2) the types of interventions performed; and 3) how the information is received, documented, and used. Survey findings suggest that vital, clinical pharmacy activities occur everyday in hospitals. Yet hospitals of all types, sizes, and teaching affiliations are struggling to use the information to improve the prescribing process. See the full survey results to help maximize your capacity to reduce medication errors.