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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 members.

I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • Concentrated sodium chloride on patient care units (20)
    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 filling prescriptions.
  • 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 (22)
    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 expertise (20)
    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 A full report appears at
  • 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
  • JC Sentinel Event Alert and free flow infusion pumps (25)
    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.
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