ISMP Quarterly Action
Agenda: October - December, 1999
From the January 26, 2000 issue
One of the most important methods for preventing adverse
drug events is for organizations seek and use knowledge from
other organizations that have already experienced problems.
To make a significant impact on proactive error prevention
efforts, administrative staff and an interdisciplinary committee
at each practice site should review the following agenda to
stimulate discussion, and then take the necessary action to
minimize adverse drug events in your facility. The following
selected items appeared in the ISMP Medication Safety Alert!
between October and December, 1999. Each item includes a description
of the problem, recommendations for safe medication practices,
and the issue number (in parentheses) to locate additional
information. The American Society of Health Care Risk Management
(ASHRM) provides the ISMP Quarterly Action Agenda to all its
members. Agenda items and pictures of some product-related
problems are also posted on our web site (www.ismp.org).
I. Look-alike/sound-alike drug names, ambiguous or
look-alike labeling and packaging
II. Misinterpretation or miscommunication of drug orders
- ZYPREXA (olanzapine) and ZYRTEC
Problem:Zyprexa, an antipsychotic agent,
and Zyrtec, an antihistamine, are often stored near each other,
and both are available as white, film coated, 5 mg and 10
mg tablets. Mix-ups have resulted when the wrong bottle was
retrieved from storage or when poorly handwritten orders were
Recommendation: Build alerts into pharmacy
computer systems, use auxiliary labels on drug containers,
and separate the storage of these products. Assure that patients
know the product's name and are aware of the potential for
a mix-up. Encourage them to ask prescribers to list the drug's
indications on all prescriptions.
- PLENDIL (felodipine) and ISORDIL
(isosorbide dinitrate) (22)
Problem: A cardiologist in Texas was
held liable for a fatal medication error after a pharmacist
misinterpreted a poorly handwritten order for "Isordil 20
mg q 6 hours" as Plendil.
Recommendation: Encourage patients to
ask their physicians to list the drug's purpose on all prescriptions.
Make transition to computerized physician order entry a priority.
- New PERCOCET (oxycodone and acetaminophen)
tablet strengths (2.5/325, 5/325, 7.5/500, and 10/650 mg)
Problem: Although this product is a combination
of oxycodone and acetaminophen (e.g., Percocet 5/325), initial
marketing material from the product's manufacturer instructed
prescribers to order it using the oxycodone component alone
(e.g., Percocet-5). Serious errors can occur if the mg of
oxycodone is misinterpreted as the number of tablets to administer
(e.g., five tablets).
Recommendation: Staff education and reminders
on containers may be helpful but not completely effective.
If possible, delay use of Percocet until the new nomenclature
is well established in the healthcare community. Clarify all
Percocet orders that appear to require more than two tablets.
- PROLEUKIN (aldesleukin) and NEUMEGA
Problem: Proleukin, used for metastatic
renal cell carcinoma, is often referred to as "interleukin-2,"
"IL-2," or "IL-II." Neumega, a platelet growth factor, is
referred to as recombinant human interleukin-11 ("rhIL-11"
or "IL-11"). These synonyms have been confused, and mix-ups
between the two drugs are possible.
Recommendation: Refer to these drugs
only by their brand and generic names. Educate staff and build
computerized warnings to clarify any reference to "IL-11"
or "IL-II" during order entry.
III. Discussion Items
- Dose and label confusion with phosphorus
containing products (24)
Problem: Variation in the way prescribers
express doses of potassium and sodium phosphate injection
has led to error prone conversions between mg, mEq, and mM
for the phosphorous component of products as well as inattention
to the amount of potassium or sodium delivered with each dose.
Also, oral and parenteral product labels can be confusing
because they list five different measurement units (mg, mM,
mEq, mOsmol, and mL) when expressing the container's volume
and strength of various salts and other ingredients. Recently,
label information confused a nursing supervisor who retrieved
the drug from the hospital pharmacy after it had closed, which
resulted in an overdose.
Recommendation: Establish a written protocol/standard
order form for phosphorous replacement therapy. Order phosphorus
supplements in mM of phosphorus and mEq of potassium or sodium
in parentheses. Build alerts into computer systems to warn
of excessive doses. Prohibit access to the pharmacy after
hours or create a "night formulary" in a specific dispensing
cabinet. Place auxiliary labels on vials in the cabinet to
- Abbreviations for morphine and magnesium
Problem: A handwritten order to "Increase
Mg to 1.5 grams per liter" was misread as "Increase MS ."
The patient received morphine 1.5 g instead of magnesium sulfate
1.5 g and suffered a respiratory arrest. "MSO4"
and "MgSO4" have also been confused.
Recommendation: Prohibit use of these
potentially dangerous abbreviations.
- Two dissimilar products referred to as
Problem: Edetate calcium disodium (CALCIUM
DISODIUM VERSENATE), used to treat acute and chronic lead
poisoning, and edetate disodium (ENDRATE; DISOTATE),
used to treat hypercalcemia and ventricular arrhythmias associated
with digitalis toxicity, are both referred to as EDTA.
Recommendation: Confirm the patient's
diagnosis to help distinguish between the two products before
dispensing or administering either drug. Encourage prescribers
to avoid abbreviation of the nonproprietary name and include
the brand name.
- "Prescription mapping" for drug storage
to minimize error (20)
Problem: While storing drugs alphabetically
by brand or generic name can assist staff in locating drugs
in the pharmacy, it increases the likelihood of misidentification
errors, primarily from confirmation bias.
Recommendation: Separate products with
look-alike names. Store products according to volume of use,
not alphabetically. Improve efficiency by reducing the distance
staff must travel when dispensing medications. Use pharmacy
computer software with "prescription mapping" features to
assist staff in easy location of products.
- Lack of stocking the full variety of dosage
strengths available for products (21)
Problem: Pharmacies may stock a limited
variety of the dosage strengths available for drugs such as
COUMADIN (warfarin) and SYNTHROID (levothyroxine). Combinations
of partial or multiple tablets may be needed to dispense a
single dose, and detailed and sometimes confusing directions
for administration may be necessary.
Recommendation: Stock the full variety
of strengths available to avoid confusion with drug administration
directions and minimize the possibility of error.
- Maintaining patient safety in the face
of staff reduction (21)
Problem: Error prevention efforts by
pharmacists and nurses may not be widely appreciated if productivity
is compromised to enhance patient safety. Many reported errors
have resulted when practitioners felt significant pressure
to place productivity above patient safety, especially when
faced with inadequate staffing.
Recommendation: Make safety an explicit
goal that should not be sacrificed in favor of productivity.
Allow front-line practitioners to eliminate some production
work, not safety work, and identify safety practices to assure
critical defenses remain intact. Establish realistic contingency
plans for unexpected staff absences.
- Safe practice recommendations for using
phytonadione (AquaMEPHYTON, vitamin K-1) (22)
Problem: Severe reactions, including
fatalities, have occurred during and immediately after intravenous
injection of phytonadione, even when the medication is diluted
and rapid infusion is avoided.
Recommendation: Oral administration is
the safest route for phytonadione. Many patients with excessive
anticoagulation respond by simply withholding warfarin and
administering oral phytonadione (MEPHYTON).
- Extraordinary similarities exist between
infection control and medication error prevention (23)
Many similarities exist between medication error
reduction and infection control. Both require targeting the
multiple system-based causes. We should open our eyes to the
evidence provided by infection control efforts in the US and
recognize the immense value of employing trained, dedicated
practitioners for the sole purpose of medication error surveillance
and proactive error control planning (please
see related Safety Brief in the Jan 26, 2000 issue).