The following are excerpts from the newsletter
- Medication error
or professional judgement?
- Safety Briefs
- Even commonly used handheld calculators can mislead
people and cause errors as this safety brief proves.
- ADVAIR DISKUS (fluticasone propionate and salmeterol
as powder for oral inhalation) dosing errors.
- The NCCMERP has released new verbal order guidelines.
- June 18-22 is the second annual National Healthcare
Risk Management Week. The theme this year is "Healthcare
Risk Managers: Creating a Safe Community for Patients,
Staff and Visitors." For more information, go to www.ashrm.org.
- To help meet one of JC's new patient safety standards
that requires documentation of medication safety competencies,
a medication administration video entitled, "Principles
of Medication Administration," is available through
ISMP. The video offers basic information to support
safe and accurate medication administration practices
and can be viewed during orientation or as a refresher
for nurses. Along with the video you will receive a
post-test that provides 1 hour of nursing CE credit,
a medication "pass" guideline to use as an education
and audit tool, a "do not crush medication list," and
numerous written guidelines and procedures that address
safe medication practices. The price of the videotape
is $50 plus postage. Orders may be placed by Phone,
Fax or the ISMP Web site. Please
click here to access the order form.
- Bridge Medical Inc. has recently published a white
paper entitled, "The Effect of Barcode-enabled Point
of Care Technology on Medication Administration Errors."
The white paper includes a description of barcode technology
and a literature review that covers the benefits of
medication barcode systems and barriers to effective
use. The paper also presents case studies on three early
adopters of the technology. Visit www.mederrors.com
to view and print a copy.
- Caution is advised if you use PRECEDEX (dexmedetomidine),
a sedative for mechanically ventilated patients, and
the antiemetic ZOFRAN (ondansetron). These vials appear
very similar with teal caps and teal, purple and blue
labeling. Zofran may appear in medication drawers of
post-operative patients if the drug is prescribed for
nausea and vomiting. If Precedex vials are mistakenly
placed in the patient's medication drawer and accidentally
given IV push, instead of by infusion as intended, it
would increase the risk of clinically significant episodes
of bradycardia and hypotension that have been associated
with administration of dexmedetomidine. ISMP has informed
Abbott Laboratories, the manufacturer of Precedex, about
the problem. Here is a picture of the vials:
- Insights into people
will improve our safety systems
- Put JC and ISMP newsletter to work!
Since January 1, 2001, JC has required organizations
that seek accreditation to proactively address all issues
covered in their publication, Sentinel Event Alert, in an
effort to prevent similar occurrences in their own organizations.
Also, following and reacting to information published in
the ISMP Medication Safety Alert! helps to demonstrate a
proactive approach to error reduction and contributes to
meeting another patient safety standard. The full story
is in this issue of our newsletter.
- ISMP / MSA Survey:
Perceptions regarding a non-punitive culture in healthcare
- Safety Briefs
- · Hazard Alert! A front panel band on the carton of
Rugby brand Pain & Fever Drops (acetaminophen drops)
suggests that it is comparable to INFANTS' TYLENOL Concentrated
Drops (acetaminophen drops). Both products contain acetaminophen,
100 mg/mL, which has had a history of confusion with
children's acetaminophen elixir (160 mg/5 mL). Mothers
who were instructed to give a "teaspoonful of Tylenol"
to their child have used the concentrate in error. In
1997, the July 16 and October 22 issues of the ISMP Medication Safety Alert! discussed fatal acetaminophen
overdoses, and a September Dateline NBC highlighted
another overdose victim, a child who needed a liver
transplant. In our June 16, 1999 issue, we reported
a hospital error where a child with fever was prescribed
"10 mL of acetaminophen per protocol." The nurse used
Infants' Tylenol instead of children's acetaminophen
elixir. These overdoses led McNeil Consumer Products
to redesign the label of Infants' Tylenol drops to emphasize
the concentrated form. They also developed a special
SAFE-TY-LOCK package with floppy "cusps" in the bottle's
neck that admit a dropper, but act as one-way valves
to prevent outward gravity flow of the concentrated
suspension, making it difficult to pour teaspoonful
amounts (see photo in the June 16, 1999, issue on our
web site). While the Tylenol product has these safety
features, the Rugby product does not, as other manufacturers
are not required to use similar packaging. Further,
Rugby's outer carton does not list a concentration.
It states only that "each dropperful contains 80 mg."
Worse, once the carton is discarded, the dropper bottle
does not list the strength or concentration. If a different
dropper is used, the wrong dose may result. Also, the
label does not state that it is a concentrated form.
It's difficult to understand why Rugby and other generic
manufacturers aren't responsible for following the safety
standard established by McNeil. We've alerted FDA to
investigate generic acetaminophen concentrated drops
packaging. Meanwhile, continue to remind parents about
the different concentrations.
- · Avoid calcium phosphate precipitation with Trissel's
newest publication. Trissel's Calcium and Phosphate
Compatibility in Parenteral Nutrition (TriPharma Communications,
Houston, TX 77225-0124; tel. 713-838-2334) is a pocketsize
resource that combines available research and other
information on the subject.
- · The FDA received a report about a potential medication
error related to promotion of RISPERDAL (risperidone).
Bottles of complimentary antibacterial gel promote Risperdal
by name on the container. Might someone think the gel
is actually Risperdal oral? Here's a photograph: