ISMP Quarterly Action
Agenda: October - December, 2000
From the January 24, 2001 issue
One of the most important methods for preventing adverse
drug events is for organizations to be proactive by seeking
and using knowledge from other organizations that have already
experienced problems. To make a significant impact on error
prevention efforts, administrative staff and an interdisciplinary
committee at each practice site should review the following
agenda to prompt 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 April and June, 1999. Each item includes a description
of the problem, recommendations for safe medication practices
and the issue number (in parenthesis) to locate additional
information. The American Society of Health Care Risk Management
(ASHRM) provides the quarterly ISMP Action Agenda to all its
I. Look-alike/sound-alike drug names, ambiguous or
look-alike labeling and packaging
- Concentrated sodium chloride on patient care units
Problem:: A vial of sodium chloride injection 23.4%
was taken from floor stock and administered IV to a neonate
instead of a normal saline flush. The infant died from acute
hypernatremia. Death or permanent central nervous system
impairment has occurred in many similar cases.
Recommendation:Remove sodium chloride concentrations
above 0.9% from patient care areas! If sodium chloride must
be a part of floor stock, sequester the drug and use auxiliary
labels that clearly state the total content of sodium.
- Zantac (ranitidine) and Zyrtec (cetirizine) (22)
Problem: ZANTAC (ranitidine) syrup (Glaxo Wellcome)
has been confused with ZYRTEC (cetirizine) syrup (Pfizer).
The proprietary names look and sound alike, increasing the
potential for medication errors.
Recommendation: Separate storage of stock bottles
of Zantac and Zyrtec. Encourage prescribers to include the
drug's indication and desired mg/mL concentration to guide
proper drug selection. The dose should also be expressed
in mg, not just volume (mL or teaspoonfuls). Place reminders
on stock bottles and install pharmacy computer alerts to
advise staff about the risk for an error.
- Flomax (tamsulosin HCl) and Volmax (albuterol) (23)
Problem: While Flomax and Volmax container labels
are not similar, confusion is possible because the names
are similar, both are available in a 100-count bottle, and
the dosage strengths differ by one decimal point. Flomax
is available as 0.4 mg capsules and Volmax is available
as 4 mg and 8 mg extended-release tablets.
Recommendation: With verbal and written orders, prescribers
should include a leading zero when stating or writing the
strength of Flomax (0.4 mg), and include the indication
with orders for either drug. If verbal prescriptions are
necessary, ask prescribers to spell the name also. Ensure
that patients who are prescribed either drug understand
the indication and are alerted to the risk for errors when
- Gentamicin 40 mg/mL injection (24)
Problem: A recent backorder of gentamicin 40 mg/mL,
2 mL vials, has led many hospital pharmacies that lack total
IV admixture programs to dispense the 20 mL multiple-dose
vial of gentamicin (40 mg/mL) to patient care units. Errors
have occurred because this packaging has been mistaken as
a ready-to-use IV piggyback container and the drug's concentration
has been mistaken as the total amount of drug in the vial.
Recommendation: Avoid dispensing gentamicin 20 mL
multiple-dose vials directly to nursing units. If patient-specific
doses cannot be dispensed, list the dose and volume of gentamicin
to be administered (e.g. 80 mg = 2 mL) clearly and distinctly
on the pharmacy label.
- Calcium gluconate injection (25)
Problem: The label states "0.465 mEq Ca++/mL" in
bold print on the front, but also states, "each mL contains
calcium gluconate 94 mg" in the fine print on the back.
The label further mentions "9.3 mg Ca++/mL" in bold in another
area. Variations in the way prescribers express the dose
of calcium gluconate and confusion surrounding the various
dose expressions on the label have led to errors.
Recommendation: The dosage of parenteral calcium
should be standardized at each practice site. Develop protocols
for the use of calcium gluconate (and other electrolyte
solutions) to address proper dose expression of elemental
calcium, dose limits, labeling methods, infusion rates,
and necessary monitoring parameters. Require independent
checks of all calculations and dose preparations for electrolyte
solutions. Whenever possible, have all IV infusions prepared
in the pharmacy.
II. Dangerous abbreviations, confusing dose designations,
and other unsafe ways of communicating orders
- Use of "IU" for international units confused with "IV"
for intravenous (21)
Problem: The abbreviation "IU"(international units)
has been misread as "IV" (intravenous). For example, there
have been reports of orders for Bicillin 600,000 IU initially
seen as 600,000 units IV. In another case, an order for
Vitamin E 400 IU daily was misinterpreted as an order for
Vitamin E 400 mg IV.
Recommendation: Never abbreviate "international units"
as IU. In most cases, the word "international" can be eliminated.
Spell the word "units" fully and include the route of administration
within drug orders to minimize the possibility of error.
- Problem with decimal points (23)
Problem: An order written for morphine ".5 mg" instead
of "0.5 mg" was misread by a pharmacist as 5 mg. The drug
was dispensed for a newborn who later died from the overdose.
Recommendation: Always use a zero before a decimal
point when the number is less than a whole unit. If feasible,
list both the microgram and milligram dose to avoid confusion.
For example, the morphine dose above could be expressed
as 500 mcg (0.5 mg). Establish a process to ensure that
the patient's age and weight are available in the pharmacy
computer system to help staff screen for an excessive dose.
- Orders to "continue previous meds" (22)
Problem: While complete drug orders are basic to
medication safety, prescribers may transfer this responsibility
to patients, nurses, and pharmacists at the most vulnerable
periods in the healthcare continuum: admission, post procedure,
transfers to a different level of care, and discharge. Too
often, orders to simply resume or continue medications have
led to errors.
Recommendation: Prescribers should always write complete
medication orders. An initial list of "home medications"
should not be used to guide the prescribing process until
it has been verified through an effective reconciliation
process. Educate patients to bring a current list of medications
(or actual drug containers) to the hospital when admitted
to help with the verification process.
- "Misspeakers" who "shoot from the hip" (24)
Problem: There have been occurrences of "misspeaking"
by healthcare providers who feel a need to say something
authoritative, despite their lack of knowledge on the issue.
Healthcare providers are often pressured to give an answer
instantly, causing "misspeaking." Serious errors are possible
when misinformation is introduced into patient care.
Recommendation: Enhance awareness among educators,
managers, and administrators about the impact that their
teaching or management style may have on staff's behavior.
They should serve as role models and demonstrate that staff
should not be afraid to admit that they do not know the
answers to all questions. Rather than rushing people for
any answer, they should allow adequate time for staff to
provide the correct answer.
- Voice messaging systems and telephone answering devices
Problem: Voice messaging systems and telephone answering
devices have been widely used to accept new and renewal
orders in community pharmacies. However, one of the most
important safety checks cannot occur: repeating back the
order to validate interpretation.
Recommendation: The safest practice is to speak directly
to pharmacy staff when calling in orders. If this is not
possible, fax the prescription after calling it in, especially
for critical drugs, or have the patient take the prescription
to the pharmacy when picking up the medication. Also mention
the drug's indication to help avoid misinterpretation.
III. Other discussion items
- Admitting "overflow" patients to units without proper
Admitting "overflow" patients to a unit where staff may
not have the expertise for typically prescribed drug therapy
is problematic. When a patient is admitted to a unit different
than might be expected (e.g., pediatric patient in an adult
unit; AMI patient admitted to a surgical ICU), the pharmacist
should communicate important information to the staff who
must deal with unfamiliar drugs, especially in situations
where "high alert" drugs are ordered. Clinical pathways,
care maps, and standard orders for treating patients with
specific conditions also can help clearly communicate orders
and drug administration procedures to nurses who are unfamiliar
with the prescribed drug therapy.
- The Leapfrog Group announces Purchasing Principles
and Safety Standards (23)
The Leapfrog Group announced its Purchasing Principles and
Safety Standards and the results of an independent analysis
estimating how many medication errors and deaths could be
prevented if the Leapfrog Safety Standards were met by every
non-rural hospital in the country. A press release can be
seen at www.brtable.org/press.cfm/464. A full report appears
- Survey shows weaknesses persist in hospital medication
error reporting systems (23)
Based upon 417 responses to the recent ISMP Survey on Medication
Error Detection, Reporting, and Analysis, it is clear that
we need to pay greater attention to the processes involved
and the environment in which these functions take place.
A large percentage of respondents reported poor confidence
in the frequency and accuracy of error reporting in their
facility. Results also indicated that a punitive environment
still persists when medication errors are discovered. In
addition, most facilities still rely upon and compare error
rates derived from error reports, despite continued encouragement
by ISMP and other groups not to do so. Complete survey results
are available at www.ismp.org.
- JC Sentinel Event Alert and free flow infusion pumps
According to the latest JC Sentinel Event Alert (November
30, 2000), surveyors from the Joint Commission on Accreditation
of Healthcare Organizations (JC) will begin to inquire
about health care organizations' use of infusion pumps without
free-flow protection. Free-flow pumps should be removed
from service and replaced with safer devices. If you are
unsure if free-flow is possible with current equipment,
take a pump out of operation and start an infusion with
the disposable set properly inserted into the device housing.
Turn the pump off and remove the set without engaging manual
flow control clamps. If you must take an action to stop
flow, rather than take an action to begin flow, the pump
is free-flow capable and potentially dangerous.