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
I. Issues Related to Communication
of Prescribed Medications
II. Issues Related to Patient Information,
Patient Education, and Medical Devices
- "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.
- Improving your pneumococcal vaccine administration
Problem: The omission of pneumococcal vaccine
is a common medication error with a major impact on public
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)
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
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)
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
- 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,
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)
- 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
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
- 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
- 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
the CE for Nurses