ISMP Quarterly Action
Agenda: January - March, 2002
From the April 3, 2002 issue
One of the most important ways to prevent medication
errors is to proactively seek and use knowledge from other
organizations that have already experienced similar problems.
To promote such a process, administrative staff and an interdisciplinary
committee at each practice site should review the following
material to prompt discussion and stimulate action to reduce
the risk of errors. The following selected items appeared
in the ISMP Medication Safety Alert! between January
March 2002. Each item includes a description of the
problem, recommendations for safe medication practices, and
the issue number (in parentheses) to locate additional information
as desired. Agenda items are posted on our web site and many
product-related problems can be visualized in the ISMP Medication Safety Alert! section. ACPE credit is available for pharmacists
(see www.ismp.org for details). The American Society of Health
Care Risk Management (ASHRM) routinely provides the ISMP Quarterly
Action Agenda to all its members.
I. Look-alike/sound-alike drug names and
other product-related issues
- K PHOS NEUTRAL and NEUTRA PHOS K (4)
Problem: A bone marrow transplant patient had been
receiving phosphorus replenishment with 2 tablets TID of
K PHOS NEUTRAL (8 mmol phosphorus, 1.1 mEq potassium
and 13 mEq sodium). However, upon discharge, this was substituted
with NEUTRA PHOS K packets (8 mmol of phosphorus,
14.25 mEq of potassium). Later, the patient was hospitalized
with hyperkalemia and EKG abnormalities.
Recommendation: To avoid confusion, phosphorus supplements
should appear in computer systems as mmol of phosphorus
and mEq of potassium and/or sodium. Computer generated labels
(and medication administration records in hospitals) also
should list both ingredients. Alerts should be built into
the system to warn users about the potential for excessive
- Opium tincture and "camphorated tincture of
opium" (paregoric) (4)
Problem: A 51-year-old woman with chronic diarrhea
died after receiving a teaspoonful of opium tincture (about
50 mg morphine) instead of a teaspoonful of paregoric (about
2 mg of morphine). The patient's physician had prescribed
paregoric by its synonym, "camphorated tincture of
opium." Paregoric has just 0.4 mg/mL of morphine while
opium tincture contains 10 mg/mL.
Recommendation: Consider the need for these products.
If paregoric must remain on the hospital formulary, never
refer to it by its synonym. Place poison labels on containers
of opium tincture and indicate the strength of morphine
(10 mg/mL). Computer alerts during order entry can remind
staff about product differences and warn against excessive
doses. Dispense opium tincture only in small dropper bottles
or unit dose packaging for individual patients. Never dispense
it in the original container as a floor stock item.
- DIPRIVAN (propofol) and DITROPAN (oxybutynin chloride)
Problem: A nurse called the pharmacy to ask for a
morning dose of DIPRIVAN that was "missing."
Upon checking the patient's electronic drug profile, the
pharmacist could not find an order for Diprivan. He learned
that the "missing" drug was being used for bladder
spasms and realized the patient was on DITROPAN.
Recommendation: Avoid dispensing "missing"
medications without properly verifying that there is an
active order for the patient. Additional investigation should
identify a reason for all missing doses, otherwise mistakes
in dosing or frequency may not be recognized.
- VIOKASE 8 (pancrelipase, protease and amylase) (6)
Problem: An order was written for "Viokase 8
tabs" with meals three times daily. A pharmacist checked
to make sure that a VIOKASE 8 tablet was used, not
eight tablets of Viokase. The manufacturer recently renamed
the product using numerical suffixes (8 or 16) to differentiate
the two available strengths of the lipase component (8,000
units or 16,000 units). These numbers could be confused
easily for the number of tablets needed per dose.
Recommendation: Place reminders on drug containers
and install alerts in computer systems to remind staff about
potential confusion. Take steps to assure that nursing staff
has properly transcribed orders. Prescribers should include
the needed tablet strength in terms of units of lipase (e.g.,
Viokase 8,000 units).
- TIMENTIN (ticarcillin and clavulanate potassium)
Problem: TIMENTIN 3.1 grams IV was ordered for a
patient in a hospital without 24-hour pharmacy. A nursing
supervisor entered the pharmacy and accidentally removed
a pharmacy bulk package containing 31 grams of drug. As
a result, the patient later received two 31 gram doses and
died from acute renal failure and congestive heart failure.
The supervisor and nurse both confused the containers, which
look very similar. In addition, they misread "31 grams"
as 3.1 grams.
Recommendation: Nonpharmacist access to a pharmacy
inventory after hours should be eliminated. For recommendations
on safe medication access when a pharmacist is unavailable,
please see our May 30, 2001, newsletter issue.
II. Dangerous abbreviations, confusing dose designations,
and other unsafe ways of communicating orders
- Cutting errors out of the operating room (5)
Problem: During a carotid endarterectomy for a 62-year-old
patient, a surgeon verbally ordered a dose of heparin which
was heard by an anesthesiologist as "2,000" units.
When the activated clotting time (ACT) was reported as 201
seconds (desired level 300-350), additional heparin was
needed. Upon review, it was learned that the surgeon had
actually prescribed 10,000 units, not 2,000 units.
Recommendation: Repeat all verbal orders using a
digit-by-digit technique for the dose. If possible, perform
"read back" (e.g., circulating nurse or anesthesia
staff writes the verbal order then reads it
back to the prescriber). Announce the drug therapy immediately
before administration. Match the drug and dose to the patient's
condition. Use protocols to standardize drug therapy and
decrease reliance on memory.
- Colchicine dose limits (3)
Problem: An order for colchicine "2 mg IV followed
by 0.5 mg IV every six hours until pain resolved" was
written for a 72-year-old man with acute gout. The dose
was written exactly as it appeared in several well-known
drug references. Subsequently, the dose was increased to
1 mg every 6 hours. After a total of 11.5 mg of colchicine
was administered in a 3-day period, the patient developed
leukopenia, abdominal pain, renal failure and metabolic
acidosis that led to respiratory distress.
Recommendation: Do not exceed 4 mg per week for IV
doses. Deaths have been reported with as little as a 7 mg
cumulative IV dose. Reduce the dose in geriatric patients
with compromised renal or hepatic function. GI symptoms
occur rarely with IV administration and should not be used
as an indicator of toxicity. Use computerized clinical alerts
to warn staff about excessive cumulative and single doses.
III. Other discussion items
- PCA dosing by proxy (5) and (6)
Problem: PCA means patient controlled analgesia,
not family controlled analgesia. With PCA, the patient
himself provides a measure of safety because analgesia happens
at doses lower than what is needed for sedation. An over-sedated
patient will not push the PCA button to give additional
Recommendation: Bypassing this built-in safety feature
is potentially dangerous. Patients, staff and family members
must be warned against dosing "by proxy" in order
to avoid a potentially dangerous aspect of PCA. Nurse controlled
analgesia using a PCA infusion device may be used in some
settings and offer advantages, but protocols and appropriate
assessment tools must be in place to gauge the level of
pain, sedation and respiratory status.
- Practitioner access to the Internet (6)
Problem: A pharmacist who did not have Internet access
in his pharmacy accidentally overlooked important information
about medications a platelet donor was taking. As a result,
the procedure was postponed for erroneous reasons.
Recommendation: Clinician access to the Internet
is a necessity, not a luxury. In addition to its value as
a research, education and communication tool, staff can
access reliable sites (e.g., ISMP, ASHP, FDA, USP) for up-to-date
information about drug shortages, hazard alerts, error reporting,
and other crucial medication information.
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