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ISMP Quarterly Action Agenda: January - March 2001

From the April 4, 2001 issue

The following selected items appeared in the ISMP Medication Safety Alert! between January - March 2001. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information. One of the most important methods for preventing adverse drug events is for organizations to be proactive by seeking and using knowledge from other organizations that have already experienced problems. To make a significant impact on error prevention efforts, administrative staff and an interdisciplinary committee should review this agenda to prompt discussion, and then take the necessary action to minimize adverse drug events in your facility. The American Society of Health Care Risk Management (ASHRM) provides the ISMP Quarterly Action Agenda to all its members. A list of agenda items is also posted on our web site (, and in many cases, product-related problems can be visualized in the ISMP Medication Safety Alert! section. ACPE credit is available for pharmacists. See our web site for details.

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

Bedford brand vecuronium/acetazolamide injection and azathioprine/inamrinone injection (1)
Problem: Side-by-side, vials of vecuronium and acetazolamide look dangerously similar. Since one is a neuromuscular blocking agent, a mix-up could prove fatal. Both azathioprine and inamrinone injection are packaged in 100 mg, 20 ml vials. After reconstitution, azathioprine is a yellow solution, similar to inamrinone (formerly amrinone).
Recommendation: Bedford will be making significant label improvements, but the newly labeled products may not reach inventories right away. For now, hospitals and group purchasing organizations should seek an alternate vendor for one of the products in each pair.

RAPAMUNE (sirolimus) unit dose liquid packets (2)
Problem: The label identifies the strength of the liquid as 1 mg/mL, but it is available in 1 mL, 2 mL and 5 mL packets. Volume is listed on a very highly stylized, colorful label, but it is in tiny print. We've received error reports and concerns about mix-ups between the various size containers, which could result in dosing errors.
Recommendation: Alert all inpatient and ambulatory pharmacies to the potential for error. Wyeth Laboratories reports that efforts are underway to improve the labeling. Until then, pharmacy-applied auxiliary labels can help prevent errors.

TAXOTERE (docetaxel) and TAXOL (paclitaxel) (3)
Problem: Look-alike and sound-alike confusion between these two drugs has resulted in errors. Practitioners have reported concern about packaging and labeling similarity between the 30 mg and 100 mg Taxol cartons. There have also been twenty-one errors in Taxotere reconstitution due to overfill in the drug and diluent vials.
Recommendation: Name confusion can be averted if prescribers print brand and generic names on prescription orders since the generic names do not look similar. Preprinted order forms are also useful. When reconstituting Taxotere for injection concentrate, add all of the enclosed diluent. To avoid selecting the wrong Taxol container, physically separate the storage of the two strengths. If possible, avoid stocking multiple sizes. Add maximum dose alerts for Taxotere (100 mg/m2) to computers.

DEPAKOTE ER (divalproex sodium extended release) and DEPAKOTE (divalproex sodium delayed release) (3)

Problem: Depakote ER is a new tablet formulation of extended release divalproex sodium for migraines. Maximum frequency of administration is once daily. Depakote delayed release tablets, an enteric coated product, can be taken more than once daily. The two formulations are not substitutable. Dosing errors have been reported when the two drugs have been mixed up.
Recommendation: Educate staff about the different dosing schedules and indications for both formulations. Initiate a computerized alert to remind about potential mix-ups. Design computer mnemonics to prevent the drugs from appearing on computer screen simultaneously (or place appropriate alerts on the screen). Be wary of verbal orders since "ER" could sound like "DR," which has been used unofficially for the delayed release product.

HUMULIN R U-500 insulin (6)

Problem: While searching for regular insulin in the refrigerator, a nurse saw the familiar brand name, Humulin R (regular insulin) but did not notice the U-500 concentration. A statement printed in red on the label warns "high potency" and "not for ordinary use." However, the font size is small and the warning was overlooked while the large, bolded "R," common to both concentrations, was easily seen.
Recommendation: As with all insulin products, incorporate an independent double check before administering in healthcare settings. If possible, have pharmacy prepare U-500 insulin doses to eliminate storage on nursing units.

II. Dangerous abbreviations, confusing dose designations, and other unsafe order communication

Symbols increase risk of medication errors(4)
Problem: The "greater than" and "less than" symbols have been used incorrectly or misunderstood. For example, a physician wrote to hold warfarin if the "INR < 2.5" when he meant "above" 2.5. One dose was withheld inappropriately. Similar errors have been reported previously.
Recommendation: Use "greater than" and "less than" as text, not symbols.

Fraudulent telephone orders (1)
Problem: A number of case reports of fraudulent telephone orders have been reported over the past ten years.
Recommendation: Minimize the number of health care providers who are authorized to accept telephone orders to better assure that the voice and manner of the caller are easily recognized. If the person receiving the order is not able to recognize the caller, a phone number should be requested and, after verification in a medical staff directory, the health care provider should call the prescriber back for the order.

III. Other items - for collaborative interdisciplinary discussion

Penmanship classes for doctors (1)
Problem: Penmanship classes are being taught at some hospitals with the hope of improving physician handwriting. While marginal improvement may occur initially, it is unlikely to be sustained. Even orders written with good penmanship can be misinterpreted. Handwritten orders also do not allow automated clinical screening in a way that reminds and warns about potential adverse events.
Recommendation: Penmanship courses should not give the public or health system a false sense of security. Establish strategic plans and realistic timelines to implement computerized methods for prescribing that have been proven to reduce errors and address common clinical problems, including illegible handwriting.

Concomitant use of heparin products (1, 4)
Problem: Three deaths have been reported within the past few months due to concomitant use of low molecular weight heparin and unfractionated heparin, which demonstrates that safeguards may not be in place.
Recommendation: Thorough review of the patient's total drug regimen is key to safe use of all medications, including heparin. Protocols, guidelines, and standard order forms should prominently remind practitioners to assess all drug therapy (including in the ED) and avoid concomitant use when indicated. A system must be in place to communicate all orders for heparin products to the pharmacy (including those prescribed in the ED if patients are admitted) so that screening can occur for unsafe duplication of products and contraindications.

Sodium chloride 3% solution distributed by central supply (5)
Problem: A pharmacist discovered that the central supply department was sending bags of 3% sodium chloride solution to a patient care unit without pharmacy knowledge. Both 3% sodium chloride and 0.9% sodium chloride solutions (500 mL) were stored in the same cabinet.
Recommendation: Every hospital should have a list of potentially dangerous IV solutions including sodium chloride injection above 0.9% that should ONLY be distributed by pharmacy. Regular pharmacy review of central supply's IV solution inventory and distribution patterns is also recommended to avoid similar errors.

IV administration set spiked into enteral nutrition container (6)
Problem: Many ready-to-hang, closed enteral nutrition containers can be spiked with a standard IV infusion set, allowing the formula to flow freely. With increasing use of opaque IV fat emulsions, 3-in-1 TPN, and lipid-based drugs, professionals cannot rely on visual appearance to determine suitability of administering solutions by the IV route. Similar containers for TPN and enteral nutrition increase the risk of error.
Recommendation: If you are using a closed enteral nutrition system, alert practitioners to this potential for error. Affix large, bold auxiliary warning labels in prominent places on the container stating, "WARNING! For enteral use only." Attach an appropriate enteral administration set with a rubber band before the product is sent to patient care units.

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