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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 for details).

I. Dangerous abbreviations, dose designations, and other methods of communicating drug information

  • 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 (21)
    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)
    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)
    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)
    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.
II. Problematic names, labels and packaging of products
  • GEODON (ziprasidone) injectable labeling ambiguity (21)
    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)
    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)
    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)
    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 (24)
    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)
    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 are used.
  • DILAUDID (hydromorphone) dosing (22)
    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)
    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 errors.
  • Tricks of the mind (cognitive and visual illusions) (22)
    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)
    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 (22)
    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
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