ISMP Action Agenda: October - December,
From the January 27, 1999 issue
One of the most important methods for preventing adverse drug
events is for organizations to seek and use information from
other organizations that have already experienced problems.
To facilitate this, we urge each practice site to have an
interdisciplinary committee review the following agenda items
to prompt discussion and recommend action necessary to prevent
these adverse drug events. Additionally, please share the
agenda with front line practitioners as well as senior leadership,
such as the CEO and vice presidents. The American Society
of Healthcare Risk Management (ASHRM) will also be enclosing
this agenda with their bimonthly newsletter sent to all members.
The following selected items appeared in the ISMP Medication Safety Alert! between October and December, 1998. Each
item is followed by a description of the problem and our recommendations
to promote safe medication practices. For additional information,
the 1998 issue number(s) is also listed in parenthesis.
I. Look-alike/sound-alike drug names, ambiguous or look-alike
labeling and packaging
II. Miscommunication or misinterpretation of drug orders
- NARCAN (naloxone) and NORCURON (vecuronium)
Problem: Names may look alike with handwritten orders
or sound alike with verbal orders.
Recommendation: If possible avoid unit stock of Norcuron.
Restrict storage to anesthesia trays or other segregated
limited access containers. Use Marsams brand, which
states WARNING: PARALYZING AGENT on the vials red
- KETALAR (ketamine) and CEREBYX
Problem: Labeling on Ketalar (currently distributed
by Monarch Pharmaceuticals but previously by Parke-Davis)
and Cerebyx (Parke-Davis) is causing confusion since total
volume and concentration are listed in different locations
on package and carton labels. Monarch has revised Ketalar
package labeling and is awaiting FDA approval. Even after
approval, there will be a delay until new packages reach
drug inventories. ISMP has not been advised of forthcoming
Cerebyx label changes.
Recommendation: Whenever possible, avoid using these
drugs until the labeling is revised; store drugs in the
pharmacy only; if the drug must remain in floor stock, provide
vials with the smallest amount of drug possible; add auxiliary
labels that list total vial contents.
- DEPO-MEDROL (methylprednisolone acetate) (20)
Problem: Cartons containing 1 and 5 mL vials appear
identical. The 1 mL vial is a single use vial while 5 mL
vials contain the preservative benzyl alcohol, which is
Recommendation: Caution staff about these look-alike
products and highlight the section on the label that mentions
benzyl alcohol contents with pen or marker.
- Bausch and Lomb, CibaVision ophthalmic products (22)
Problem: Manufacturers are converting to a therapeutic
class based color code system to facilitate identity. When
combined with similar corporate logos, fonts and graphics,
the slight color variations make it difficult to differentiate
products within each pharmacological class.
Recommendation: Buy products within same class from
different vendors to assure visual dissimilarity. Do not
store products by brand.
- ONCASPAR (pegaspargase) (25)
Problem: Graphics on the 5 mL vial carton label make
it appear as if the entire vial contains 750 international
units when actually that is the per mL concentration; each
vial contains 3,750 international units.
Recommendation: Add auxiliary labels and alert all
staff to the potential for misinterpretation.
- REMERON (mirtazapine) (24)
Problem: 15 mg and 30 mg tablet strengths have containers
with similar labeling.
Recommendation: Apply auxiliary labels to clearly
identify tablet strengths.
- NEUMEGA (interleukin 11) and HERCEPTIN
Problem: The diluent volume needed for reconstitution
differs from that supplied by the manufacturer; incorrect
preparation could result in wrong dose and/or product waste.
Recommendation: Inform staff and place auxiliary
labels on diluents to communicate the proper volume necessary
for reconstitution, or remove and discard diluents when
products arrive and supply your own when preparing drugs
(Neumega: sterile water for injection; Herceptin: bacteriostatic
water for injection.
III. Miscellaneous errors and adverse drug reactions
- Use of decimal dosages (24)
Problem: A patient received 25 mg of morphine instead
of 2.5 mg. Numerous other ten fold overdoses have been reported
when decimal points are overlooked.
Recommendation: Where possible, prescribe using the
nearest whole number, or use fractions (such as 2 ½mg)
rather than decimal points (such as 2.5 mg).
- VERSED (midazolam) Syrup (23)
Problem: Past history of overdose errors with chloral
hydrate liquid in pediatric patients should guide safe use
of Versed Syrup, which is also used for conscious sedation.
Recommendation: Specify the dose in mg, not volume.
Avoid ambiguous dosing frequency, such as for two
doses or prn agitation. Allow only trained
practitioners to administer the drug in monitored settings.
Do not dispense for home administration. Stock only one
- Insulin (23)
Problem: Numerous serious errors have been reported
with this high alert drug, often related to the misinterpretation
of u as zero (10U interpreted as 100 units)
or mix-ups with other products.
Recommendation: Prohibit the abbreviation u
for units; accept only emergency verbal orders for IV insulin;
assure that all insulin infusions are prepared in the pharmacy;
use a standard concentration of 1 unit/mL to eliminate the
need for double concentrations; apply auxiliary warnings
to alert staff to its presence in IV fluids.
- Patient instructions for warfarin (24)
Problem: Two patients were hospitalized after unclear
written or verbal warfarin instructions were misunderstood
as the number of tablets to be taken instead of the mg amount
(eg. 5 tablets vs 5 mg).
Recommendation: Include mg amount and number of tablets
in the directions and verify that patients clearly understand.
IV. For discussion
- Oral solutions in parenteral syringes (23)
Problem: A nurse drew a digoxin elixir dose out of
a stock bottle using a tuberculin syringe and inadvertently
administered the drug IV.
Recommendation: Have pharmacy prepare unit doses
of all liquid oral medications using specially designed
and labeled oral syringes that will not connect to IV line
ports. Provide all patient care units with oral syringes
for use with all liquid oral products.
- ATROVENT (ipratropium) inhalation aerosol contraindicated
in peanut-allergic patients (21)
Problem: Neither the package label nor the tear off
patient instruction sheet mentions contraindication in patients
allergic to soya lecithin or related products such as soybeans
Recommendation: Gather and utilize information about
a patients food allergies; assure that your current
computer system alerts staff to this potentially serious
food and drug interaction.
- Minimizing errors with automated dispensing equipment
Problem: While these devices can streamline the distribution
process, they may also increase error risk if established
check systems are bypassed.
Recommendation: Consider using systems that require
pharmacy order entry before nurses remove drugs. Carefully
select the drugs that will be stocked in cabinets. Minimize
the supply and stock drugs in the smallest doses and containers.
Develop a check system to assure accurate cabinet stocking.
- Error rates cut by computer order entry or clinical
pharmacy input (22)
A JAMA study (Bates et al. 1998;280:1311-16) indicates that
computerized physician order entry can reduce preventable
adverse drug events by 55%.
- Shared eye drop bottles (22)
Problem: Using communal eye drops to prevent waste,
control costs or for convenience increases the risk of infection
and medication error (when a single dispensing error can
affect multiple patients).
Recommendation: Do not share eye drops. Purchase
in unit-of-use packaging or have patients fill prescriptions
for eye drops prior to surgery and bring them in for procedures.