ISMP Quarterly Action
Agenda - October-December 2002
From the January 9, 2003 issue
One of the most important ways to prevent medication
errors is to seek and use knowledge proactively from other
organizations that already have experienced similar problems.
To promote such a process, administrative staff and an interdisciplinary
committee at each practice site should review the following
material to prompt discussion and stimulate action to reduce
the risk of errors. The following selected items appeared
in the ISMP Medication Safety Alert! between October-December
2002. Each item includes a description of the problem, recommendations
for safe medication practices, and the issue number in parentheses)
to locate additional information as desired. Many product-related
problems can be visualized in the ISMP Medication Safety Alert!
section of our website. The American Society of Healthcare
Risk Management (ASHRM) routinely provides the ISMP Quarterly
Action Agenda to all its members. Continuing education credit
related to this issue of the newsletter is available for pharmacists
and nurses (see www.ismp.org for details).
I. Dangerous abbreviations,
dose designations, and other methods of communicating drug
II. Problematic names, labels and packaging
- Confusing the @ sign for a number (20)
Problem: A pharmacy label for an octreotide
infusion stated to run the solution "@5ML/H,"
but the rate was misread as 25 mL when the typewritten @
symbol was mistaken as the number "2."
Recommendation: Don't use the @ symbol when prescribing
medications. Maintain a space before and after abbreviations
to avoid misinterpretation.
- Concentration expressed as dilution or percentage
Problem: The concentrations of most medications
are stated in mg or mcg per mL, but a few drugs (e.g., epinephrine,
lidocaine) have concentrations expressed as a dilution ratio
or percentage. These expressions are error-prone. Studies
show that knowledge about converting ratio/percentage concentrations
to mg/mcg doses is inadequate, even among physicians. Errors
have been reported due to confusion between concentrations
(e.g., 1:10,000 and 1:1,000).
Recommendation: Do not expect staff to be familiar
with converting percent/ratio expressions to mg or mcg/mL
doses. Store a single concentration for these products whenever
possible. Create a dose conversion chart reflecting concentrations
that are available in your facility and post them on code
carts and in other areas where emergency medications may
be prepared. Review the dose chart for emergency drugs during
annual CPR certification.
- Use of volume alone to express liquid doses (23)
Problem: Only the volume was specified for the dose
of oxycodone solution. With both a 1 mg/mL and a 20 mg/mL
concentration available, the patient accidentally was given
the higher concentration, resulting in an overdose.
Recommendation: Always prescribe liquid medications
by metric weight. If prescribed by volume, clarify the concentration.
Computerized prescriber order entry, pre-printed order forms
and protocols can prompt physicians to properly express
doses. Where possible, stock just one concentration of oxycodone.
- Drug names that end in "L" (22)
Problem: Misreading of the terminal "L"
in orders for both TEGRETOL (carbamazepine) and AMARYL (glimepiride)
resulted in dosing errors.
"Tegretol300 mg" was misinterpreted as 1300 mg,
and "Amaryl2 mg" as 12 mg.
Recommendation: Ensure proper spacing between the
drug and dose on handwritten orders, printed materials,
computer screens, pharmacy labels, etc.
- Methotrexate injection given by the oral route (21)
Problem: Inaccurate information from a patient's
family prompted a nurse practitioner to order "methotrexate
injection 80 cc every Sunday." But the patient had
been taking 0.8 mL of the injectable solution orally once
weekly (less costly than tablets), and had been using an
insulin syringe to measure the dose (80 units = 0.8 mL).
The nurse was told that the patient was taking 80 "cc,"
not 80 units, each week.
Recommendation: Avoid writing or accepting orders
without a route of administration, or with a volumetric
dose only. Verify information provided by patients/family,
especially if the medication history seems unusual or unexpected.
Carefully balance affordability with risk and safety and
identify potential problems before prescribing medications
in an unconventional way.
- GEODON (ziprasidone) injectable labeling ambiguity
Problem: The product label states the concentration
(20 mg/mL) after reconstitution, but not the total amount
in the vial (30 mg), which potentially can be withdrawn
from the vial. The labeling also specifies directions for
storage after reconstitution, but the product contains no
preservatives (single use only). This may lead to inappropriate
use as a multiple dose vial.
Recommendation: Alert pharmacists to this problem.
If nurses must reconstitute the product (e.g., pharmacy
closed), provide the vial and diluent in a zip-lock bag
with directions for withdrawing the correct dose after reconstitution.
Discard the vials after a single use.
- Vaccines and neuromuscular blockers (25)
Problem: In Taiwan, seven infants received atracurium
instead of hepatitis B vaccine due to look-alike vials and
storage of both medications near each other in the refrigerator.
One infant died. Similar mix-ups have happened in the US.
Recommendation: Consider using prefilled syringes
for vaccines. Limit storage of neuromuscular blockers to
essential areas only (e.g., OR, PACU, ED, critical care).
Sequester the products away from other drugs and affix "WARNING
- PARALYZING AGENT" labels to vials and syringes.
- ZANAFLEX (tizanidine) and GABITRIL (tiagabine);
AXERT (almotriptan) and ANTIVERT (meclizine) (21)
Problem: Similar generic names and dosing have lead
to confusion between tizanidine and tiagabine. Confusion
between Axert and Antivert has
been reported because their names are similar and the dose
of meclizine (12.5 mg) is an exact multiple of the dose
of almotriptan (6.25 mg).
Recommendation: Build alerts into pharmacy computers,
use auxiliary labels on drug containers, and separate the
storage of these products. Assure that patients know the
product's name and encourage them to ask prescribers to
list the drug's indications on all prescriptions.
- Insulin combination products (HUMALOG MIX 75/25,
HUMULIN 70/30, NOVOLOG MIX 70/30, NOVOLIN 70/30) (24)
Problem: Name/dose similarity and confusion regarding
the various different insulin combination products has led
to a growing number of reported errors.
Recommendation: Perform a failure mode and effects
analysis before adding these products to the formulary.
Consider designing a preprinted order form for insulin that
lists specific products, ingredients and component ratios.
Have pharmacy dispense doses wherever possible to ensure
an independent double check. For drug selection screens,
emphasize the word "*Mix*" along with the name
of the insulin mixtures.
III. Issues related to drug delivery devices,
drug information, staff education, and human factors
- I.V. connection ports accommodate oral syringes
Problem: Several needleless IV system connection
ports could accommodate oral syringes, thereby allowing
oral solutions to be injected IV.
Recommendation: Alert clinical staff to this potentially
dangerous situation. Label all oral syringes "FOR ORAL
USE ONLY" and consider using amber colored oral syringes
to help differentiate them from parenteral syringes.
- CETACAINE (benzocaine 14%) and HURRICAINE (benzocaine
20%) topical sprays and methemoglobinemia (20)
Problem: Topical anesthetic sprays that contain
benzocaine have been associated with methemoglobinemia,
an acute situation that decreases the
oxygen carrying capacity of hemoglobin. Reported cases often
involved multiple sprays and sprays of longer duration than
recommended. Unclear directions for use and unfamiliarity
with the significant absorption of topical anesthetics contributed
to the problem.
Recommendation: Alert clinicians to proper dosing
and to the potential for methemoglobinemia. Identify patients
at risk (e.g., children, elderly, inflamed sites of administration,
concomitant use of certain medications, G6PD deficiency)
before topical anesthetic administration. Stock one topical
anesthetic spray to increase staff familiarity. Apply auxiliary
labels to alert staff to proper dosing. Have oxygen and
methylene blue (not to be used in patients with G6PD deficiency)
available in areas where benzocaine-containing products
- DILAUDID (hydromorphone) dosing (22)
Problem: Dose recommendations in many references,
as high as 1-4 mg IV every 4-6 hours, may lead to overdoses
in opiate-naïve patients.
Recommendation: Alert staff to the possibility of
overdoses if using hydromorphone in opiate-naïve patients.
One reference (LexiComp) is updating the monograph to suggest
a reduced dosing schedule for opiate-naïve patients.
- Watch out for complacency (24)
Problem: Complacency, which occurs when we let our
experiences guide our expectations, diminishes our caution
when participating in the medication use process and allows
errors to get through the system. We are especially vulnerable
to complacency when technology is used.
Recommendation: Encourage staff to identify patterns
of thinking and behaving that are likely to fuel complacency.
A staff meeting might be devoted to sharing these observations.
Use this feedback and discussions about errors that have
occurred when blindly trusting automation to develop specific
plans to work on issues where complacency could lead to
- Tricks of the mind (cognitive and visual illusions)
Problem: Look/sound-alike drugs and familiarity
with physicians' prescribing patterns are just two situations
in which our minds can be "tricked" into incorrect
assumptions and errors. Clinicians are especially prone
to these tricks of the mind when reading drug names and
strengths, judging the spatial location of products stored
in a pharmacy, and selecting the correct vial size.
Recommendation: Rotate placement of fast-moving items
to avoid falling into the practice of just "reaching
and grabbing" containers. Since size may not be a reliable
cue to differentiate otherwise similar-appearing products,
set them apart using color, shape, and auxiliary labels.
Technology, such as electronic prescriptions and bar coding,
also can reduce the risk of errors.
- Intimidation presents serious safety issues (23)
Problem: Prescribers who use intimidation to dissuade
individuals who are questioning the safety of orders adversely
affect the ability of others to detect potential mistakes
and correct them before they reach the patient.
Recommendation: Cover the topic of intimidation in
policies/bylaws and during staff (including medical staff)
orientation. Address it immediately if it occurs. Apply
the "two challenge" rule - have the clinician
who is concerned about the order state the problem twice
to the prescriber, and if there is no adequate solution,
refer the situation to others for resolution.
IV. Other discussion items
- Use your pre-admission process to enhance safety
Problem: Initial contact with patients during pre-admission
assessment is brief so important information about medications
often is inadequate. One hospital estimated that 75% of
all order clarifications that pharmacists performed after
admission could have been fixed before patients were admitted.
Recommendation: Consider following the example of
one hospital that placed a pharmacy technician in the admissions
department to obtain full medication histories before patients'
scheduled admissions. The hospital reported an 85% reduction
in "home medication" discrepancies