Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook

ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - october - december 2009

From the January 28, 2010 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 items from the October-December 2009 ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP List of High-Alert Medications. The Action Agenda is also available for download in a Word format ( that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Many product-related problems can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

Oral syringes: A risk-reduction strategy that has not been fully utilized (21)
Problem: Patients continue to be subjected to a substantial and unjustifiable risk when oral/enteral products are prepared and administered in parenteral syringes, which can inadvertently be connected to an IV line. The latest victim of such an error involved a newborn infant who died after an intermittent feeding prepared in a parenteral syringe was administered IV instead of via a NG tube. According to a 2009 analysis of paid liability claims, wrong medication route claims had the highest average paid indemnity—$214,240 per case—of all medication error claims.
Recommendation:  Oral syringes have specially engineered hubs that cannot be easily or securely connected to IV lines or accommodate a needle. To promote consistent use: 1) Use parenteral tubing with ports that are incompatible with oral syringes, and enteral devices that only accommodate oral syringes and catheter tip connectors; 2) Supply all areas with oral syringes and dispense oral liquids from the pharmacy in oral syringes; 3) Notify pharmacy if liquid medications are required; 4) Establish training programs; and 5) Apply auxiliary labels to oral syringes and label all access lines.

v 4th quarter 2008 QuarterWatch™ shows increase in fentanyl patch serious adverse events due to errors (20)
Problem: Fatal and serious adverse drug events (ADEs) reported to FDA increased by 25% in 2008 compared to 2007, caused in large part by large-scale generic drug recalls. Among all drugs causing fatal and serious ADEs, fentaNYL, specifically fentaNYL patches, ranked first. The drug accounted for twice as many reports of injuries or deaths due to errors than the second ranked drug, acetaminophen, or the third ranked drug, insulin.
Recommendation:  New prescriptions for fentaNYL should not be dispensed without patient education by a doctor or pharmacist who has received special training in the safe use of this drug. Take measures such as creating guidelines, determining the indication, and limiting prescribing privileges to ensure only appropriate patients receive this drug. For further recommendations, visit:

Order scanning systems may pull multiple pages through the scanner at a time, leading to omissions  (22)
Problem: Order management scanning systems (OMSS) offer numerous advantages, but if the pharmacy never receives the orders—a situation that exists when multiple pages of orders are pulled through the scanner at the same time, thus scanning only the top page—these benefits can be compromised.
Recommendation: To reduce the risk of drug therapy omissions: 1) Remove staples, open creases, number each page, and scan one page at a time; 2) Require the sender to verify the number of pages scanned; 3) perform end-of-shift chart checks comparing the original order to the pharmacy-generated MAR; and 4) Review drug therapy during handoffs. I

 v Inaccurate dosing if insulin withdrawn from a pen (23)
Problem: Nurses at a hospital were drawing insulin doses out of pen cartridges with an insulin syringe. This practice can introduce air into the cartridge, leading to inaccurate dose measurement when using the pen. This practice may also risk contamination of the remaining medication in the pen.
Reccomendation: Provide education and guidelines for how to correctly use the insulin pens available in the hospital and why insulin should not be withdrawn from pen cartridges and used as small insulin vials.

Children harmed from hypotonic IV fluids (23)
Problem: ISMP Canada reported two pediatric deaths due to acute hyponatremia caused by IV administration of hypotonic dextrose and saline solutions. Outside the body, the osmolarity of the solution may seem appropriate, but once infused, the dextrose is rapidly metabolized, leaving a large portion of the volume extremely hypotonic and electrolyte-free. Children are particularly vulnerable to water intoxication because they are prone to developing syndrome of inappropriate antidiuretic hormone (SIADH).
Recommendation:  Standards of practice should be established for postoperative IV solutions used to hydrate patients–particularly children, and protocols should be established to identify, treat, and monitor patients with hyponatremia, water intoxication, and/or SIADH. For more recommendations, see our August 13, 2009 newsletter (

TAMIFLU (oseltamivir) oral suspension dosing in mg not mL (20)
 The Tamiflu product label recommends prescribing doses in milligrams (mg), which corresponds with the oral syringe in the Tamiflu box that is marked in 30, 45, and 60 mg increments; however, many prescribers order liquid medications by volume (i.e., milliliters [mL] or teaspoons), which makes it impossible to measure the dose using the oral syringe that comes with the drug. This has led to confusion.
Recommendation: Remind prescribers that they need to prescribe Tamiflu doses in mg if the measuring device that comes with the drug is to be used. If pharmacists receive prescriptions with volume doses, they should clarify the dose with the prescriber and ensure that the pharmacy label matches the way the drug will be measured.

Seasonal influenza vaccines falsely believed to provide protection against H1N1 (21)
Some healthcare practitioners believed the 2009-2010 seasonal influenza vaccine provided protection against the H1N1 2009 virus because the label notes that the seasonal influenza vaccine includes the A/Brisbane/59/2007 (H1N1) strain. This virus strain, however, was not responsible for the H1N1 2009 pandemic. The strain used for the H1N1 2009 vaccine is A/California/7/2009 (H1N1)
Recommendation: Educate practitioners and consumers that the seasonal influenza vaccine does not provide protection against the H1N1 2009 influenza virus strain.

Look-alike packaging of FLUMIST (influenza vaccine live [intranasal]) and H1N1 intranasal vaccine sprayers (22)
Pre-filled, single-use intranasal sprayers of FluMist and the new Influenza A H1N1 2009 vaccine look very similar (both from MedImmune). Mix-ups occurred with 13 children at an immunization clinic who were scheduled to receive the injectable seasonal influenza vaccine (FLUZONE) and the intranasal H1N1 2009 vaccine; however, the children received two doses of seasonal influenza vaccine (one Fluzone and one FluMist) but no H1N1 2009 vaccine. 
Recommendation:  To differentiate seasonal flu and H1N1 2009 vaccines: 1) Store on different shelves/separate refrigerators; 2) Use separate coolers when transporting to clinics; 3) Separate administration areas during group immunizations; 4) Have two practitioners independently check each other when vaccines are prepared for shipment to offsite immunization clinics and at the time of administration; and 5) Do not pre-populate vaccine administration logs with lot numbers.

Lower colchicine dose effective and safer for acute gout (20)
The first single-ingredient oral colchicine product, COLCRYS, received FDA approval to treat familial Mediterranean fever (FMF) and acute gout flares. As a part of the approval process, a lower dosage schedule (1.2 mg followed by 0.6 mg in 1 hour, for a total of 1.8 mg) was found to be as effective as the previously recommended higher dose.
Recommendation:  Encourage prescribers to use lower and less frequent Colcrys doses for gout flare-ups and FMF, particularly if combined with drugs that inhibit the metabolism of colchicine (e.g., verapamil, clarithromycin). Dispense the Colcrys Medication Guide to patients and review it with them. Remind patients to avoid grapefruit.

Don’t be a borrower or lender of medications (23)
 Often practitioners are tempted to borrow a medication from another patient’s cassette, from a discharged patient’s unused medications, or from another patient care unit in order to speed the process of administering an unavailable dose to their patient. This workaround increases the risk of an error and potential harm to the patient.
Recommendation:  Remedy the reasons for borrowing, which are often rooted in system deficiencies or misconceptions about the clinical significance of quick administration. Ensure that nurses understand the risks of borrowing medications; ensure that pharmacists understand the risks of delayed order review and dispensing. Educate staff about how to safely resolve “missing medications.”

The importance and value of independent double-checks (25)
The value of independent double-checks has yet again been called into question. Some believe the process is not justified and could lead to more mistakes, while others feel that it just does not work. When performed correctly, however, double-checks can identify a relatively high rate of errors, as confirmation bias can often block a person’s ability to see his own mistakes. 
Recommendation:  For double-checks to be effective, they must be accomplished independently; provide education to staff regarding the appropriate method. Double-checks should also be limited to certain high-alert medications, very complex processes, and high-risk patient populations. Staff should document mistakes caught during the checking process, and they should analyze and act on these reports.

Mix-ups between dosage strengths that differ by a factor of 10 (20)
 A common form of dosing errors involves mix-ups between drug dosage strengths that differ by a factor of 10. Examples include mix-ups with ABILIFY (aripiprazole) 20 mg and 2 mg, COMPAZINE (prochlorperazine) suppositories 25 mg and 2.5 mg, and prednisone 50 mg and 5 mg. The use of trailing zeros (i.e., 5.0 mg) and naked decimal points (i.e., .5 mg) increases the risk that a 10-fold dosing error will occur. 
Recommendation:  Avoid using naked decimals (e.g., write 0.5 mg instead of .5 mg) and trailing zeros (e.g., write 2 mg instead of 2.0 mg) on all prescriptions (written and electronic), computerized medication selection screens, and pre-printed order forms. Ultimately, we hope that FDA and manufacturers will market strengths that are above or below the exact 10-fold difference.

Risk of chondrolysis with continuous intra-articular infusion of local anesthetics (23)
FDA has received approximately 35 reports of chondrolysis (necrosis and destruction of cartilage) in patients given continuous intra-articular infusions of local anesthetics using elastomeric infusion devices to control postoperative pain. 
Recommendation:  FDA is advising health professionals not to use any type of pump for continuous intra-articular infusion of local anesthetics. The agency is also requiring affected pharmaceutical companies and pump manufacturers to include a warning about this serious side effect in their labeling.

CETACAINE (benzocaine 14%, butamben 2%, tetracaine hydrochloride 2%) bottles with Luer connector   (24)
Cetacaine liquid, a local anesthetic which is not suitable for injection, is now available in a bottle with a dispenser cap that is compatible with any Luer-lock syringe. The ability to draw the liquid into a parenteral syringe and the potential for unlabeled syringe mix-ups should be a cause for concern in any patient care area where parenteral injections may be administered.
Recommendation: Avoid using this form of Cetacaine if there is a possibility it may end up in an area where parenteral injections are administered. We contacted the company and suggested the use of a non-Luer connector with directions to use a non-parenteral syringe, and that “Topical Use Only” labels be supplied with the product. 

The National Patient Safety Agency (NPSA) releases lithium safety alert   (25)
The National Patient Safety Agency in England and Wales sent an alert to all healthcare organizations where lithium therapy is initiated, prescribed, dispensed, and monitored, requesting compliance with safe treatment practices established by the National Health Service, which include informing patients of the known side effects or symptoms of lithium toxicity and the need to schedule regular blood tests.  
Recommendation: Consider developing a patient education program on lithium based on the supportive material for health professionals, as well as a patient information booklet, lithium alert card, and a record book for tracking blood tests; examples can be found at the following link:


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


Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved