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The following are excerpts from the newsletter
October 3,
2002
- Benzocaine-containing topical
sprays and methemoglobinemia
- ISMP Quarterly Action Agenda:
August - October 2002
Safety Briefs
- Add the "at" sign, @, to your dangerous
abbreviations and symbols list. An error happened with
a handwritten "at" symbol. In this case, an
order for an infusion with sodium bicarbonate to run
"@50 cc/h" was misread as 250 mL per hour.
- A concentrated liquid medication was prescribed for
sublingual administration. The order was transcribed
onto the MAR and it appeared with the abbreviation
"SL" as the route of administration. A recent
nursing graduate misinterpreted the abbreviation as
"saline lock" and administered the oral solution
intravenously.
- An order for "Mirapax 1/2 cap daily" was
received in the pharmacy. No strength was specified.
The pharmacist realized that this might be an order
for the Anti-Parkinson's drug MIRAPEX (pramipexole),
but it's available as a capsule in several different
strengths. The pharmacist reviewed the patient's chart
and found that he had been taking MIRALAX (polyethylene
glycol) for constipation.
- We recently heard about a problem with DURAGESIC
(fentanyl transdermal system) patches that may not be
widely recognized. A hospital experienced two events
involving patients with severe chronic pain who were
using the patches. Both patients had removed the patches,
cut them into small pieces, soaked the pieces in water,
and injected the solution into themselves intravenously
- It doesn't pay to play the percentages
- The right "route" to safety- A rheumatologist's
practice to prescribe injectable methotrexate for oral administration
nearly led to serious harm.
- Safety Briefs
- FDA recently approved GEODON (ziprasidone)
for injection (IM use only) for rapid control of acute
agitation in schizophrenia. Although the label states
that the concentration is 20 mg per mL after reconstitution
with 1.2 mL of sterile water for injection, neither
the label nor the package insert mentions that this
creates a total volume of 1.5 mL (30 mg).
- Name Alert I: A pharmacy staff member inadvertently
stocked ZANAFLEX (tizanidine), a drug used for
muscle spasticity, instead of GABITRIL (tiagabine)
, which is used for seizure disorders
- Name Alert II: A prescription for AXERT
(almotriptan) 6.25 mg with directions to take 1-2 tablets
at once, and repeat in 2 hours if needed up to 25 mg/day.
The dispensing pharmacist was not familiar with Axert
and misread the prescription as ANTIVERT (meclizine).
- A physician who intended to start his patient on RHEOMACRODEX
(low molecular weight dextran) called the order in to
a nurse as "Rheo 10 cc/hr." The nurse interpreted
the order as REOPRO (abciximab).
- We hope you know that your error reports do so much
good!! Are you also aware that ISMP can be used as a
single portal for reporting errors to several national
organizations at once? A single contact with ISMP via
e-mail, web site, telephone (800 FAIL SAFE), or in person (at meetings
for example) can be used to activate the USP-ISMP Medication
Errors Reporting Program. This assures you that the
following organizations will be notified: United States
Pharmacopeia, Institute for Safe Medication Practices,
FDA MEDWATCH Program, ECRI (for device-related problems),
and pharmaceutical manufacturers (for all product-related
problems). Best of all, you can be sure that your information
will contribute enormously to patient safety by informing
others about potential problems and allowing us to influence
changes in products and practices. Although your information
is secure with us and your identity and location are
never made public, you can report anonymously or specify
if you don't want to be identified to FDA, the company,
etc. (we prefer to be able to make contact with people
since follow up is sometimes necessary). ISMP always
respects any specified wishes of the reporter as to
the level of detail to be included in our publications.
- Tricks but no treats: Illusions
and medication errors
- Use your pre-admission process to enhance safety
- Are you using your pre-admission process for elective
admissions to help protect patients from medication errors?
- ISMP launches
newsletter for consumers - ISMP is excited to announce
a new, easy-to-read, newsletter designed especially for
patients and non-clinical hospital employees. Called Safe
Medicine, this monthly publication is unique because
it focuses exclusively on preventing medication errors.
It's reasonably priced and available in both print and electronic
formats. Copies can be distributed to residents in your
community as part of your marketing program, or to patients
and families who visit the hospital, clinics, waiting areas,
the emergency room, community meetings, or health fairs.
Employees also can receive the newsletter monthly along
with their paycheck. In addition to protecting your workforce
from medication errors, Safe Medicine can
help change the organization's culture and involve all employees,
including non-clinicians, in hospital-wide efforts to reduce
medication errors. We also can offer just the content of
the newsletter for your own publication or work with you
to brand the newsletter using your organization's name along
with ours. Visit our web site (www.ismp.org)
to review our premiere issue and learn how you can subscribe.
- Safety Briefs
- LexiComp recently decided to revise dosing recommendations
for hydromorphone (DILAUDID) based on advice
from clinical experts. Other changes in the monograph,
including advice for opiate tolerant patients, appear
on our website in the "Textbook
Errata" section.
- A nurse called the pharmacy to report that an automated
dispensing cabinet was filled with Baxter's potassium
chloride 40 mEq/100 mL instead of 10 mEq/100 mL minibags.
- Please join us as we host our 5th annual ISMP Cheers
Awards Dinner and Banquet on Tuesday, December 10, 2002,
at 6 p.m. in the Hilton Atlanta during the ASHP Midyear
Clinical Meeting. Peter Kilbridge, MD, Practice Director
for First Consulting Group, will be the keynote speaker.
Kenneth N. Barker, PhD, Professor of the Department
of Pharmacy Care Systems at Auburn University School
of Pharmacy will receive our second annual ISMP Lifetime
Achievement Award. A discount is available for newsletter
subscribers who purchase tickets independently. Corporate
sponsors and guests also are welcome. Please show your
support through a donation or sponsorship of tables
for honorees and guests. All proceeds benefit ISMP safety
activities and donations are tax deductible. Please
see our
website or call 215 947 7797 for details.
- Beware of drug names that end in the letter "L."
Two overdoses were reported last week because a lower
case “L” was the end letter in a drug name
and was misread as the number 1. In the first case,
an order for 300 mg of TEGRETOL (carbamazepine)
BID was misinterpreted as 1300 mg BID. The patient had
just been transferred from another facility. The letter “L” at the
end of Tegretol had been written very close to the numerical
dose of 300 mg on the patient’s transfer order
form (Tegretol300 mg). When a nurse transcribed this
medication onto a hospital order form, she misread the
dose and wrote an order for Tegretol 1300 mg BID. The
pharmacist who processed the order was unfamiliar with
the medication and the pharmacy computer system did
not alert him that the dose exceeded safe limits. The
patient received only one dose in error before a clinical
pharmacist caught the mistake. Fortunately, the patient’s
Tegretol level had been low, so the dose made him lethargic,
but not seriously toxic. In the other case, a nurse
misread an order for 2 mg of AMARYL (glimepiride)
as 12 mg because there was insufficient space between
the last letter in the drug name and the numerical dose
(see figures on our web site). But in this case, the
pharmacist processed the order correctly and the error
never reached the patient. That’s because the profile
on the automated dispensing cabinet stated the dose
correctly. Adequate spacing between the drug name and
the dose also is crucial on medication history forms, preprinted
order forms, and electronic formats such as the pharmacy
computer, computer-generated medication administration
records, and
computerized order entry systems. For example, even
a clearly typed order for 25 mcg of LEVOXYL (levothyroxine)
could be misread as 125 mcg if it appears without proper
spacing as Levoxyl25 mcg, especially since both strengths
are available.
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