ISMP Quarterly Action
Agenda - October-December 2003
From the January 29, 2004 issue
One of the most important ways to prevent medication
errors is to learn about problems that have occurred in other
organizations, and to use that information to prevent similar
problems at your practice site. To promote such a process,
the following selected agenda items have been prepared for
your administrative staff and an interdisciplinary committee
to stimulate discussion and action to reduce the risk of medication
errors. These agenda topics appeared in the ISMP Medication Safety Alert! between October and December 2003. Each item
includes a brief description of the medication safety problem,
recommendations to reduce the risk of errors, and the issue
number (in parentheses) to locate additional information.
Continuing education credit is available for pharmacists and
I. Information about the
patient or medication
II. Communication of medication orders
- Miscommunication of patient lab values (24)
Problem: Miscommunication of what was thought
to be blood glucose values led to the unnecessary administration
of insulin to a group of patients. A nurse found a list
of patient names with accompanying room numbers. She mistakenly
thought the room numbers were blood glucose values and
gave each patient insulin according to a standard insulin
sliding scale protocol.
Recommendation: Implement standardized procedures
to communicate both verbal and written patient information,
including read-back of verbal test results and designating
a standard place, such as a medication administration
record (MAR), to record lab values.
- Toxicity from blue dye (20)
Problem: Adding FD&C Blue No. 1 dye to enteral
feeding solutions to detect pulmonary aspiration has led
to toxicity, in some cases manifested by refractory hypotension,
metabolic acidosis, and death. Patients with increased
gut permeability (from sepsis) are at greatest risk for
toxicity. Other blue dyes may have similar toxicity.
Recommendation: Do not add dyes to enteral feedings.
A glucose oxidase test strip has been shown to be more
accurate in detecting aspiration.
- Question all unclear orders (21)
Problem: An order for LANTUS (insulin glargine)
10 units was crossed out and changed to 8 units. The cross
out was not visible on the pharmacy copy, so the pharmacist
entered the dose as 108 units, which appeared on the MAR
the following day. The high dose was accepted and given
without question because the prescriber was a well-respected
Recommendation: Question unusual orders, even
if the prescriber has extensive experience. One good rule:
double-check any new subcutaneous insulin order above
50 units, and any IV insulin order above 25 units. Compare
all entries on the previous 24-hour MAR with each new
MAR to verify correct interpretation of orders.
- "SSRI" - does it mean sliding scale regular
insulin or selective-serotonin reuptake inhibitor (24)
Problem: A physician ordered "d/c SSRI"
(meaning sliding scale regular insulin) if the patient
required no further insulin for 48 hours. Two days later,
a nurse followed through and wrote "d/c SSRI"
on a pharmacy communication sheet. However, the pharmacist
discontinued the patient's selective-serotonin reuptake
inhibitor instead of the sliding scale regular insulin.
Recommendation: Avoid using "SSRI" as
an abbreviation for either intended meaning.
- Folic acid and folinic acid (20)
Problem: Some prescribers may order the chemoprotectant
drug, leucovorin calcium, as folinic acid. Clinicians
have sometimes dispensed and administered folic acid by
mistake, leaving the patient unprotected from chemotherapy-related
Recommendation: Refer to leucovorin calcium using
its full name. Never use folinic acid or just leucovorin,
which could be confused with the anticancer drug LEUKERAN
- Thalidomide and flutamide (21)
Problem: A verbal order for flutamide was misheard
as thalidomide. Errors are more likely with these sound-alike
products because both may be used to treat prostate cancer.
The restricted distribution program for thalidomide helped
prevent this error from reaching the patient.
Recommendation: Never accept verbal orders for
chemotherapy; read-back of the order alone may not prevent
- Updated list of error-prone abbreviations and dose
With the 2004 National Patient Safety Goals calling for
organizational compliance with a list of prohibited dangerous
abbreviations, acronyms, and symbols, ISMP offers an updated
list (www.ismp.org) to assist healthcare facilities in
III. Drug labeling, packaging, and nomenclature
- Using color to reduce error potential (23)
The use of color to reduce the risk of errors requires
careful consideration of the distinct differences between
color-coding, color differentiation, and color matching.
Color-coding is sometimes used to classify and identify
products, but it hasn't been tested scientifically as
a way to reduce errors, and there's evidence that it actually
contributes to errors. Color differentiation (using color
to make things stand out) and color matching (using color
to link two items like a plug and outlet) may be more
- "No bacteriostat added" does not mean
"preservative free" (23)
Problem: The front label panel on Faulding's morphine
vial states "No bacteriostat added," making
it appear to be safe for epidural or intrathecal use.
However, a statement in small print on the side label
panel states "Not for epidural or intrathecal use.
Contains sodium metabisulfite."
Recommendation: We've asked FDA to encourage the
company to move the warning "Not for intrathecal
use" to the front label panel. In the meantime, make
staff aware of the problem for this and other similarly
labeled products, and affix auxiliary labels on those
- Morphine and fentanyl/bupivicaine mix-up (22)
Problem: A nurse accidentally selected a bag of
IV morphine (intended for PCA) instead of fentanyl/bupivicaine
intended for an epidural infusion for a patient in labor.
Both products (Baxter Compass, a line of parenteral products
recently sold to PharMedium) were packaged in brown overwraps
to shield the solutions from light. The patients
respiratory status deteriorated and the infusion was stopped,
after which the error was noticed.
Recommendation: Apply distinctive auxiliary labels
on both sides of the overwraps (and the cartons stored
in the pharmacy) to alert clinicians to the contents and
route of administration. Store the products in separate
locations, and avoid having the products delivered to
the pharmacy on the same day.
- Death from intrathecal use of ionic contrast media
Problem: A young man died after misadministration
of ionic contrast media for myelography instead of nonionic,
water-soluble contrast media. This and other reported
fatalities illustrate the neurotoxic potential of ionic
contrast agents when mistakenly administered intrathecally.
FDA-required warnings to avoid intrathecal use have not
been wholly effective in preventing these errors.
Recommendation: Perform a failure mode and effects
analysis on contrast media used at your institution. Recognize
that these agents are not just standard floor stock items
and re-evaluate pharmacy's role in distributing the products.
Make sure a pharmacist checks all contrast media that
leaves the pharmacy. Determine all sites where the contrast
media may be stored and separate the ionic and nonionic
products. Affix auxiliary labels to ionic media to alert
staff not to give it intrathecally.
- Daptomycin (CUBICIN) and dactinomycin (COSMEGEN)
Problem: Similar generic names led to a mix-up
between daptomycin, a new antibiotic, and dactinomycin,
a cancer drug. Differences in dosing helped to detect
the error before it reached the patient, but both agents
are given once daily, supplied as lyophilized powders,
and reconstituted to a yellowish solution, adding to the
risk of error.
Recommendation: Build name alert warnings in the
pharmacy computer, verify the product's indication before
dispensing either drug, and use shelf stickers to alert
staff about these look-alike drug names.
- 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.
- Confusing drug name suffixes (21)
Problem: The proliferation of drug name suffixes
(XL, SR, ER, CD, LA) has led to dispensing errors among
different formulations for products such as WELLBUTRIN
(bupropion), METADATE and RITALIN (methylphenidate),
and DEPAKOTE (divalproex).
Recommendation: Teach staff about the different
formulations and dosing schedules. Verify all new orders
for these medications. Design computer mnemonics so different
formulations do not appear on the computer screen simultaneously,
or place appropriate alerts on the screen. Post warnings
on pharmacy shelves.
IV. Other items for discussion
- Barriers to patient education (20)
An ISMP survey showed that most hospital nurses feel
they have little or no written drug information and medication
safety materials to offer patients. When written materials
are available, most nurses felt it did not cover important
information clearly, or it seemed unsuitable for patients
because of perceived health literacy, reading level, or
language barrier issues. Nurses also cited time constraints
as a formidable barrier to patient education. Pharmacists
can help by working with nurses to make suitable written
materials more readily available for patients; develop
error-prevention materials for high-alert medications;
and consult with patients who have been identified by
nurses and physicians as needing focused education. Physicians
can help by listing discharge medications in the progress
notes so nurses can begin patient teaching early.
- High-alert medications: Different perspectives
An ISMP survey showed that nurses and pharmacists did
not always agree on which drugs should be considered high-alert
medications (those that bear a heightened risk of causing
significant harm when used in error). For example, nurses
identified IV adrenergic antagonists and agonists, oral
or IM narcotics, and liposomal forms of drugs as high-alert
medications more often than pharmacists. Pharmacists felt
more strongly than nurses that hypertonic sodium chloride,
warfarin, and subcutaneous insulin were high-alert medications.
The survey also uncovered some large gaps between the
drugs that respondents felt were high-alert medications
and the adoption of special precautions to mitigate errors
and harm when using these drugs. Review the survey findings
to stimulate discussion at your practice site. Our recently
updated list of high-alert medications will also help you prioritize your error-reduction strategies
in 2004. Information about the patient or medication
The ISMP Quarterly Action Agenda is
now approved for Continuing Pharmaceutical Education
by the Pennsylvania Society of Health-System Pharmacists.
Each Action Agenda will be approved for one contact
hour of continuing education (0.1 CEU).
Learning objectives and instructions for applying
for CE are available at the PSHP CE Center.
Society of Health-System Pharmacists is approved
by the American Council of Pharmaceutical Education
as a provider of continuing education and complies
with the criteria for quality continuing pharmaceutical