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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - January-March 2003

From the April 4, 2003 issue

One of the most important ways to prevent medication errors is to seek and use knowledge proactively from other organizations that already have 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 October-December 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. Many product-related problems can be visualized in the ISMP Medication Safety Alert! section of our website. The American Society of Healthcare Risk Management (ASHRM) routinely provides the ISMP Quarterly Action Agenda to all its members. Continuing education credit related to this issue of the newsletter is available for pharmacists and nurses (see for details).

I. Drug Information
  • Avoid IV infusions of plain sterile water for injection (2, 5, 6)
    Instances of prescribing and administering sterile water for injection (prescribed as “plain water” or “free water”) intravenously to treat hypernatremia in patients with hyperglycemia or CHF led to several serious errors and one patient’s death from hemolysis due to the solution’s hypotonicity.

    Recommendation: Alert staff to the hazard of infusing sterile water for injection intravenously. Develop protocols for treating hypernatremia in patients with comorbid conditions such as hyperglycemia or CHF. Store large volume parenteral containers of sterile water in the pharmacy only. Do not allow sterile water to appear as a choice on prescriber order entry systems. Flash the warning “Use Only as a Diluent” on pharmacy computer screens when sterile water is entered.
  • VZIG (varicella-zoster immune globulin) and VARIVAX (varicella virus vaccine) confusion (2)
    Problem: Confusion between these products has led to administration of Varivax to pregnant women, which is specifically contraindicated in pregnancy.

    Alert clinicians to the differences in these products and use computer alerts and warning labels to remind staff. Store the products separately and obtain a pregnancy history as appropriate to help prevent fetal exposure to the vaccine.
  • Use short-acting insulin with LANTUS (insulin glargine) (6)
    Problem: Lantus provides a basal insulin level over 24 hours. To ensure proper postprandial blood glucose control, short-acting insulin also should be prescribed to control hyperglycemia after meals. Yet Lantus is often prescribed without such insulin coverage or in combination with other agents that have inappropriate pharmacokinetic profiles for mealtime coverage.

    Use short-acting insulin to control postprandial glucose levels to within specified guidelines as established by the International Diabetes Federation and the American College of Endocrinology.
  • New formulation for KAOPECTATE (5)
    Problem: Kaopectate has been reformulated to contain bismuth subsalicylate. Because the change is not readily apparent on the label, the product may be used by patients for whom it now is contraindicated (e.g., salicylate allergies, children recovering from chicken pox or the flu). The new formulation also causes dark-colored stools, which could be misdiagnosed as a symptom of gastrointestinal bleeding.

    Use auxiliary labels and computer alerts to advise clinicians of the formulation change and contraindications for use. Also, alert patients to the change if the product is likely to be used after discharge
.II. Communication of Medication Orders
  • Use “mL,” not “cc” (5)
    Problem: An order for heparin “25 cc” per hour (intended dose of 1,000 units/hour) was misinterpreted as 25 units per hour when the handwritten “cc” looked more like a “u”.

    Use “mL” not “cc” when expressing volume in handwritten, preprinted, and electronic prescriptions.
  • Several sources of error when prescribing levothyroxine (1)
    Problem: Misplaced decimal points, mathematical errors when converting milligrams to micrograms, and confusion about IV to oral dose conversion are commonly reported problems that have led to serious errors with levothyroxine products.

    Encourage prescribers to order levothyroxine in micrograms to avoid using decimal points. Build computer alerts for doses greater than 200 mcg. With the product’s long half-life, patients do not need to be switched from oral to IV levothyroxine during short periods of NPO status.
  • Standards needed for communication of electronic orders (4)
    Problem: As with handwritten orders, electronic prescriptions can lead to miscommunication if dangerous abbreviations and dose expressions are used. Other conditions unique to electronic communication of medication orders also pose a risk (e.g., the letter “l” looks like the number “1”). Standards for communication of electronic orders are needed to avoid these risks.

    With input from our subscribers, ISMP has developed and published draft standards to begin the process of establishing national standards for electronic communication. Clinicians are encouraged to provide comments. Similarly, pharmacists should take a lead role in developing internal standards for electronic (or print) communication of medication orders, working with other departments, including Information Technology.
III. Drug Labeling, Packaging, and Nomenclature
  • Packaging similarities with ketorolac and atracurium besylate (1)
    Problem: Mix-ups are possible between 10 mL vials of Baxter’s atracurium and Bedford’s ketorolac because both have similar lavender colors on the labels and gray snap-off caps.

    Sequester neuromuscular blocking agents from other medications and dispense them with auxiliary warning labels noting that the medication is a paralyzing agent. Carry only 30 mg or 60 mg vials of ketorolac, since doses should not exceed 60 mg (2 mL).
    Problem: The concentration is listed on the outside box, but not on the bottle. If the carton is discarded, there is no way to determine the milligram dose.

    The manufacturer has been notified. A change will be made temporarily and new labels will be available next year. In the meantime, alert parents to the problem and place auxiliary labels listing the concentration on the bottles before dispensing the product in inpatient settings.
  • Fatal reports of intrathecal vincristine continue (3)
    Problem: Another fatality occurred after vincristine was dispensed without a warning label on the syringe and outer wrapper (per USP standards), and the medication was administered intrathecally, along with the prescribed intrathecal chemotherapy, instead of intravenously.

    Consider dispensing vincristine in a small mini-bag (with USP-required warning labels) to differentiate it from intrathecal medications.
    Administer intrathecal medications in a designated location and have pharmacy deliver them to the specified location immediately before use. Never dispense or deliver intrathecal and IV medications together. Require at least two clinicians to independently verify intrathecal medications before administration.
  • Confusion with ABILIFY (aripiprazole) and proton pump inhibitors (5)
    Problem: The “prazole” ending in aripiprazole could lead to misclassifying this antipsychotic medication as a proton pump inhibitor.

    As new drug products are released, familiarize yourself with the indications, doses, and adverse effects before ordering, dispensing, or administering these medications.
  • Confusion between ZETIA (ezetimibe) and ZESTRIL (lisinopril) (6)
    Problem: Due to name and dose similarities, coupled with a poorly handwritten prescription, a pharmacist erroneously dispensed Zestril instead of Zetia.

    Specify the medication’s indication on prescriptions and ensure that patients know its purpose. Encourage patients never to leave the pharmacy without verifying with the pharmacist that the prescription matches what their doctor told them.
IV. Issues Related to Drug Delivery Devices, Patient Education, and Human Factors
  • New color-coding for 25 gauge safety needles may lead to errors (5)
    Problem: Globally distributed 25 gauge safety needles must conform to new international standards requiring orange color-coding. Nurses have long associated orange color-coding with insulin syringes. Recently, a nurse accidentally used a tuberculin (TB) syringe (with an attached 25 gauge needle) that had an orange plunger tip to draw up a dose of insulin. The patient received 50 units of insulin, not 5 units as prescribed, because the “.5 mL” mark (absent the leading zero) on the syringe was misread as the “5 unit” mark.

    Alert nurses that the orange color-coding is no longer used exclusively for insulin syringes. Some hospitals are using 26 gauge (brown) or 27 gauge (gray) needles on TB syringes to avoid mix-ups.
  • Failure to remove unneeded parenteral lines leads to errors (2)
    Problem: Parenteral lines left in place when no longer needed led to two serious errors. In one case, an infant’s mother injected AUGMENTIN (amoxicillin/ clavulanate) oral suspension, drawn into a parenteral syringe, into the child’s heparin lock (used previously for IV antibiotics), causing respiratory arrest. In another case, a nurse administered 25 mg of meperidine via an arterial line that was left in place inadvertently after transfer out of ICU.

    Remove all unnecessary parenteral access lines as soon as possible. Stock and use oral syringes for all oral liquid medications. Ensure clear labeling of all access lines that must be maintained, and trace each line back to its insertion site to verify the route of administration.
  • Enteral feeding given IV (6)
    Problem: Because enteral feeding bags can be spiked with an IV administration set, several cases of administering enteral feedings by the IV route
    have been reported. In many cases, the patient was supposed to receive three-in-one TPN solution, which has a similar appearance to enteral feeding.

    Use large, bold auxiliary labels on enteral feedings that state “WARNING! For enteral use only - NOT for IV use.” Also, use a rubber band to attach an appropriate enteral administration set to all enteral feedings before distribution to (or storage in) patient care units to ensure ready availability. Manufacturers have been asked to redesign the enteral bags so that they cannot attach to IV administration sets.
  • Translation inaccuracies (4)
    Problem: Studies show that interpretation errors occur about 31 times during each encounter when translators are used to communicate medical information to patients who speak a language other than English. About 63% of these translation inaccuracies could have potential clinical consequences.
    Recommendation: Ensure proper training and screening of translators. Schedule non-English speaking patients to come in on days when translators are available. With proper training, students majoring in foreign languages may be a good source for translation services.
  • Double checks are worth your time (5)
    Double checks carried out by people fail at times. But, statistically speaking, research shows that double checks are worth your time, catching 95% of errors at each verification point. To get this type of accuracy, checks need to be independently performed, and staff need to be trained on the proper technique.

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 education programming.

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