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ISMP Quarterly Action Agenda: January - March, 2000

From the April 5, 2000 issue

One of the most important ways to prevent adverse drug events is for organizations to proactively seek and use knowledge learned from other organizations that have already experienced problems. To make a significant impact on error prevention efforts, administrative staff and an interdisciplinary committee at your practice site should review the following agenda to prompt discussion, and then take the necessary action to minimize adverse drug events in your facility. The following selected items appeared in the ISMP Medication Safety Alert! between January and March, 2000. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information. A list of agenda items is also posted on our web site ( In many cases, pictures of product-related problems can be seen in the ISMP Medication Safety Alert! section of our web site. The American Society of Health Care Risk Management (ASHRM) provides the ISMP Quarterly Action Agenda to all its members.

I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • SUFENTA (sufentanil) and SUBLIMAZE (fentanyl) (1)

  • Problem: Confusion between Sufenta and Sublimaze has resulted in multiple episodes of respiratory arrest. The risk of confusion is high because both drugs are potent analgesic/anesthetic products with very similar generic names. Selecting the wrong drug via the computer mneumonic "su" has also resulted in errors.
    Recommendation: Consider removing one of these drugs from the formulary. If both drugs remain in use, educate staff about the different potency of these products and include visual reminders wherever they are stored. Configure computer screens (including those on automated dispensing cabinets) to prevent the two drugs from appearing consecutively on the same screen.
  • Confusion with caffeine citrate labeling (CAFCIT) (3)

  • Problem: Caffeine citrate (Cafcit), recently marketed by Roxane Laboratories, is labeled 20 mg/mL but practitioners can easily miss that the 3 mL vial actually contains 60 mg since the volume is not connected to the concentration statement on the package label. Also, the product is often dosed in terms of its base (10 mg/mL) and not the salt (20 mg/mL) although the package label highlights the salt.
    Recommendation: Prior to dispensing, pharmacists should apply auxiliary labels or circle the total volume to clarify the total amount in the vial. Develop a protocol to clearly delineate how the drug is to be dosed.
  • Novaplus packaging (4, 5)

  • Problem: Similarities exist between various parenteral chemotherapeutic agents packaged under the Novaplus brand. Several drugs have identical blue and white color schemes and are available in the same size cartons and vials. Vials of diltiazem injection and atracurium injection also look alike with a blue and yellow color scheme. A mix-up could prove fatal.
    Recommendation: Novation has agreed to look into the matter. For now, do not store products together on shelves, in bins, or in refrigerators. Prior to dispensing, pharmacists should enhance each package with auxiliary labels or circle the drug name to call attention to the product identity.
  • Unusual instructions for administering SPORANOX (itraconazole) IV (5)

  • Problem: The recommended dose of Sporanox is 200 mg, but each 250 mg (25 mL) ampul must be added to a 50 mL bag of 0.9% sodium chloride injection for product solubility. Only 60 mL of the resulting 75 mL solution is needed to administer 200 mg. Unless the infusion is stopped manually after 60 mL has been infused, or a volume control set or volume-limiting infusion pump is used, 250 mg will be administered in error.
    Recommendation: The manufacturer modified its preparation instructions and now recommends removing the excess 15 mL before the container is used for infusion (leaving 200 mg/60 mL).
  • Abbott CARPUJECT metoclopramide injection and metoprolol confusion (5)

  • Problem: Carpuject boxes of metoclopramide (10 mg per 2 mL) and metoprolol (5 mg/5 mL) look very similar. The drug names share the first four letters (M-E-T-O) and both packages have green and blue "rocket stripes" on the bottom right corner of the box.
    Recommendation: Use a marker to circle or "yellow out" portions of the label to help differentiate these items. Otherwise, purchase one item from a different manufacturer until Abbott enhances the packaging.
  • BENTYL (dicyclomine) Injection label confusing practitioners for the past year (6)

  • Problem: Bentyl 2 mL ampuls list the 10 mg/mL drug concentration but not the volume or the total content of 20 mg/2 mL. This has lead to confusion and numerous errors.
    Recommendation: If Bentyl ampuls are present in your practice site, add a cautionary note to each ampul to remind users of the actual contents (20 mg/2 mL). New ampuls with enhanced labeling will begin shipment in late April or May, 2000
  • Confusion when using prescription labels for non-prescription products (1)

  • Problem: A bottle of insecticide with a prescription label was confused with an oral liquid medication.
    Recommendation:When supplying units with labels, do not use pharmacy prescription labels (labels imprinted with the pharmacy's name, address, etc.). Only blank labels or other labels that cannot be confused with prescription labels should be made available outside the pharmacy.
II. Misinterpretation or miscommunication of drug orders
  • PROCAN SR (procainamide hydrochloride sustained release) dispensed for PROCANBID (procainamide hydrochloride extended release) (5)

  • Problem: Procan SR, dosed every 6 hours, was recently withdrawn from the market, but the sustained release form remains available generically. Confusion between the sustained release product and the extended release product, Procanbid, given no more frequently than every 12 hours, has resulted in dispensing errors.
    Recommendation: The two forms of procainamide are not substitutable with each other. Decide which form should remain available on formulary and consider eliminating the other item from inventories.
  • Probenecid (BENEMID) mistaken for PROCANBID (procainamide hydrochloride extended release) (5)

  • Problem: Procanbid 500 mg twice a day was dispensed after misreading a poorly handwritten order for probenecid 500 mg bid. In another case, a drug cart was misfilled with probenecid 500 mg when Procanbid 500 mg was misread on a computer printout.
    Recommendation: Use a computerized alert or auxiliary container labels to alert staff to potential mix-ups. Store drug containers apart and design computer mnemonics to prevent the drugs from appearing together on the computer screen. Know the patient's diagnosis to determine if he needs an antiarryhthmic, uricosuric, or a penicillin adjuvant.
  • After sublingual use of nifedipine rejected by experts, intended sublingual dose accidentally administered IV (1, 3)

  • Problem: After using a parenteral syringe to withdraw a nifedipine capsule's liquid content, a patient received the intended sublingual dose as an IV injection. FDA advisory panel and other experts have rejected sublingual use of this product.
    Recommendation: Prohibit the use of nifedipine by the sublingual route and use suitable alternatives to treat hypertensive emergencies. Use specially designed oral syringes that do not connect to IV tubing when preparing any oral liquid medication for inpatients.
III. Discussion Items
  • Computerized physician order entry (CPOE) will soon be required if caring for patients from some Fortune 500 companies (1)

  • CPOE is one of the safety standards being initiated by the Leapfrog Group, a think tank that represents large employer organizations and the Business Roundtable, whose members are CEOs from Fortune 500 companies. To meet the standard, hospitals will have to demonstrate that its software intercepts a minimum percentage of common, serious prescribing errors, using a testing protocol being developed by ISMP. An implementation date will soon be announced for the CPOE purchasing standard.
  • IOM report notes that oversight of the hospital's medication system might be placed under a single clinician (2)

  • The IOM report states that individuals or departments "own" a piece of the medication system, but as a rule, no one manages the system as a whole. Thus, the report suggests that a dedicated clinician (e.g., pharmacist with 50% of his or her time devoted to this role) provide oversight of the hospital's medication system and the multidisciplinary medication improvement team. Gain leadership backing and financial support for such a position. With budget preparation around the corner for many, now may be a good time to begin discussions on this important issue.
  • Full and timely disclosure of errors to patients is the best policy (4)

  • The Veterans Affairs (VA) Medical Center in Lexington, Kentucky, recently reported encouraging data on a courageous and ethical institutional policy to disclose errors to patients and to equitably compensate patients/families for their actual loss. When compared to other VA medical centers, the Lexington facility is in the top quartile for number of claims filed, but at the bottom quartile for payments. Full disclosure of errors and just compensation for injuries seems to be a solution that is both ethical and cost effective. It restores organizations and practitioners to a patient advocacy role, putting the patient's interests first, while potentially minimizing the organization's financial impact.
  • A multidisciplinary team is essential to medication error reduction efforts (5)

  • The first priority for successful error reduction efforts lies in establishing a multidisciplinary team. The multidisciplinary nature of the team significantly increases the success because effective results depend on looking at the complex medication use process as a whole and understanding how major functions interact through varied perspectives and disciplines. Equally important, leadership must demonstrate their commitment to medication safety by providing these teams with the necessary time and resources to discharge their responsibility.
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