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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - October-December 2004

From the January 27, 2005 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 2004. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number (in parentheses) to locate additional information as desired. Many product-related problems can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses.

I. Issues Related to Communication of Prescribed Medications

  • "U" for units causes insulin error (21)

    Problem: A nurse recorded a patient's home insulin dose of 4 units using "u" instead of "units." The physician misread the "u" as a "4" and wrote admission orders for 44 units of insulin. The patient received a single overdose, but was not harmed.

    Recommendation: The only safe way to express "units" is to write the word completely. The patient discovered the error after a subsequent nurse involved him in a double check of the dose.

  • Numbering orders can lead to errors (22)

    Problem: An order for TORADOL (ketorolac) 25 mg was misread as "1.25 mg of Toradol" due to placement of the numeral one followed by a period (1.) used to number the order.

    Recommendation: Avoid numbering orders, even on preprinted order forms. If orders must be numbered, each number should be circled.

  • Problems with faxed medication orders (25)

    Problem: Fax machines can promote medication errors if not properly maintained. An order for 250 mg of FLAGYL (metronidazole) was misread as 500 mg because of streaks within the faxed copy.

    Recommendation: Schedule regular fax maintenance and cleaning. Also, remind practitioners not to write in the margins of faxed orders, as these are often cut off and not visible in the faxed copy.

II. Issues Related to Patient Information, Patient Education, and Medical Devices
  • Improving your pneumococcal vaccine administration rate (21)

    Problem: The omission of pneumococcal vaccine is a common medication error with a major impact on public health.

    Recommendation: Improve consistency with vaccine screening and administration by developing physician-approved protocols. Include screening of all patients 65 and older, administering the vaccine before the day of discharge, notifying the patient's primary care provider, and maintaining a list of patients who have been vaccinated in case the patient is a poor historian.

  • Avoid mixing medications together (23)

    Problem: A hospitalized patient had a prescription bottle of medication from home containing a myriad of different strengths. The prescribed strength had been changed several times. The patient had mixed all the tablets together, and was later unable to distinguish them.

    Recommendation: Warn patients about the dangers of mixing the contents of prescription bottles. If a medication dose is changed, tell patients to bring the prior prescription bottle back to the pharmacy so the physician can be contacted and a new label with correct directions can be applied.

  • atal gas line mix-up (25)

    Problem: A patient died after receiving nitrous oxide instead of oxygen when an oxygen flow meter was connected to an adjacent nitrous oxide wall outlet in a radiology suite. The oxygen flow meter's index safety system, designed to assure connection only to oxygen wall outlets, was broken. Dim lighting also prevented the technician from distinguishing blue (nitrous oxide) and green (oxygen).

    Recommendation: Standardize the type of flow meters, regulators, and connectors used throughout your facility, and use only those with intact index safety systems. Assure that gas connections are observable, labeled, and visible under the conditions present during their use. Use clear Christmas tree adapters to prevent reliance on color-coding.

III. Drug labeling, packaging, and nomenclature

  • Metronidazole (FLAGYL) and metformin (GLUCOPHAGE) (20)

    Problem: Potentially serious mix-ups between metronidazole and metformin have been linked to look-alike packaging (both bulk bottles and unit-dose packages) and selection of the wrong product after entering MET as a mnemonic.

    Recommendation: To avoid order entry errors, program the computer to display entire names of associated products whenever the MET stem is used as a mnemonic. To reduce packaging similarity, purchase these medications from different manufacturers. Also consider stocking metronidazole in only 250 mg tablets. (Metformin tablets are not available as 250 mg tablets.) During the dispensing process, use both the order/prescription and the computer-generated label for verification (even with refills).

  • ENADRYL (diphenhydramine) FASTMELT and soy allergy (20)

    Problem: Soy protein isolate is listed as one of the ingredients in Benadryl Fastmelt, but the information is not prominent enough since the drug may be used to treat the very symptoms a soy-allergic child may experience.

    Recommendation: Alert parents of soy or peanut allergic children about the ingredients in Benadryl Fastmelt, and the importance of reading all the ingredients listed on the label of over-the-counter medications.

  • RETHINE (terbutaline) and METHERGINE (methylergonovine) (21)

    Problem: Frequent mix-ups between Brethine and Methergine ampuls, both packaged similarly, have led to patient harm and possibly fetal demise.

    Recommendation: Brethine is now available in vials, which do not resemble Methergine ampuls. To prevent errors, immediately replace terbutaline ampuls with available vials.

  • PD, tetanus, and flu vaccines (22, 24)

    Problem: Look-alike packaging has led to numerous mix-ups between FLUZONE (influenza virus vaccine) and TUBERSOL (tuberculin purified protein derivative - PPD). Prior mix-ups have also been reported between PPD and tetanus toxoid vaccines, also due to similar packaging. In some cases, physicians have prescribed PPD as "TB x 1," which can be misinterpreted as "TD x 1." All these products are also stored in the refrigerator, often side-by-side.

    Recommendation: Design a vaccine administration process that requires documentation of lot number and expiration date before drug administration to help detect errors before they reach the patient. Store these products separately and apply auxiliary labels (e.g., FLU VACCINE) when feasible.

  • ials of nitroprusside (24)

    Problem: After being removed from its carton, a nitroprusside vial was incorrectly stocked in an automated dispensing cabinet in the bin designated for dexamethasone. The vials looked very similar. One patient received the wrong drug.

    Recommendation: Stock nitroprusside vials in their original containers since the carton packaging can help distinguish it from other medications.

  • osing errors with acetylcysteine (23)

    Problem: In addition to inhalation use in chronic bronchopulmonary disease, acetylcysteine is administered orally and IV to treat acetaminophen overdoses, and IV to prevent reduced renal function during specific drug therapy (e.g., contrast media, doxorubicin). However, dosing errors have occurred because the strength is typically expressed as a percent concentration, not mg/mL.

    Recommendation: Consider stocking a new formulation of IV acetylcysteine, ACETADOTE (Cumberland Pharmaceuticals), which lists the concentration primarily in terms of mg/mL to facilitate dosing for the FDA-approved acetaminophen overdose indication.

  • ydromorphone: 1 mL fill in a 2 mL vial (23)

    Problem: Vials of hydromorphone (2 mg/mL) from Mayne Pharma (formerly Faulding) are labeled as 2 mL vials, but they contain only 1 mL of medication, leading to dosing errors and confusion when documenting waste.

    Recommendation: The label is being changed, but current inventory won't be exhausted for some time. If you have this product, make note of the problem in computer systems, on controlled-drug inventory forms, and on the vials, if possible.

IV. Issues Related to Healthcare Provider Labeling and Packagi

  • Mislabeled propofol (22, 23)

    Problem: A bottle of propofol was mislabeled and bar-coded as "10 mEq KCl in D5W/100," and administered to a patient after barcode verification. Another nurse stopped the infusion when she saw the white solution.
    Recommendation: When propofol supplies are received in the pharmacy, immediately affix a label stating that the drug "should only be given by staff certified in the use of drugs causing deep sedation." Develop and implement safe barcode labeling practices and require an automated or manual double check when adding barcodes. Treat propofol as a controlled substance and keep supplies in a locked storage unit when dispensed to patient care areas.

  • Unlabeled containers in the OR (24)

    Problem: A patient died after receiving an intravascular injection of chlorhexidine instead of contrast media. The two clear solutions were on the sterile field in unlabeled basins during a radiology procedure.
    Recommendation: Implement safe labeling practices for all medications and solutions that are used in perioperative settings, even if only one product is in use. (See the full article for vital recommendations that should be implemented). Purchase skin antiseptic products in prepackaged swabs or sponges if possible. Perform regular safety rounds in perioperative areas and consider expanding on-site pharmacy services in these areas.

  • Unlabeled irrigation solution (25)

    Problem: A nurse used Dakin's solution instead of sterile water to dilute crushed medications. The two similar-looking bottles were near each other.
    Recommendation: All extemporaneously prepared irrigation solutions should be stored and labeled in a way that clearly differentiates them from solutions that may be used systemically.

V. Other Discussion Item

  • Patient safety is NOT a priority - Reducing at-risk behaviors (19, 20)

    Patient safety should be a value associated with every healthcare priority, not a priority that can be reordered based on changing demands. Unfortunately, human behavior runs counter to making patient safety a value because the rewards for risk taking are often immediate and positive, while the punishment (patient harm) is often remote. As a result, even the most educated and careful healthcare provider will learn to master dangerous shortcuts and engage in at-risk behaviors. Part I (issue 19) explores why we engage in at risk behaviors and teaches you how to make patient safety part of your value system. Part II (issue 20) helps you determine if your culture is tolerant of risk, and suggests ways to reduce at-risk behaviors.

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.

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses


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