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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 nurses.

I. Information about the patient or medication

  • 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.

II. Communication of medication orders
  • 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 diabetologist.

    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 toxicity.

    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 (chlorambucil).

  • 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 a misunderstanding.

  • Updated list of error-prone abbreviations and dose designations (24)

    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 ( to assist healthcare facilities in this effort.

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 effective.

  • "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 commonly used.

  • 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 patient’s 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 (24)

    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) (22, 25)

    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)

    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 (21, 25)

    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.

The Pennsylvania 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 education programming.

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