ISMP Quarterly Action
Agenda - January-March 2004
From the April 22, 2004 issue
One of the most important ways to prevent medication
errors is to learn about problems that have occurred in other
organizations, and to use that information to prevent similar
problems at your practice site. To promote such a process,
the following selected agenda items have been prepared for
your administrative staff and an interdisciplinary committee
to stimulate discussion and action to reduce the risk of medication
errors. These agenda topics appeared in the ISMP Medication Safety Alert! between January and March 2004. Each item includes
a brief description of the medication safety problem, recommendations
to reduce the risk of errors, and the issue number (in parentheses)
to locate additional information as desired. Many product-related
problems may also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit
is available for pharmacists and nurses. Click
here for details.
I. Information about the
patient or medication
- Confusion with 2002 Broselow tape (4)
Problem: Practitioners have reported confusion
with the 2002 Broselow tape. For example, the tape lists
IV push drug doses in mg or mEq, but uses volumetric measures
(mL) for infusions.
Recommendation: Establish a standardized approach
to teach clinicians how to use the tape and assess preparedness
by performing regular mock codes. Have nurses open code
carts regularly to become familiar with the tape and cart
contents. Ensure that the drug concentrations in a pediatric
code cart correspond to the ones listed on the tape.
- Caution needed with flammable products (5)
Problem: Flammable medications have ignited accidentally
when exposed to a heat source (even static discharge),
yet manufacturer warnings on flammable products are poorly
visible. A 6-year-old child's infected toe was treated
with ethyl chloride spray before lancing and the entire
area burst into flames when a nurse practitioner triggered
a cautery device.
Recommendation: Ensure that all healthcare workers
are aware of the dangers of flammable products. Reevaluate
the need for these products, as there may be safer alternatives,
especially for local anesthetics. If flammable products
are used, affix auxiliary labels to clearly alert staff
to the danger.
- Expressing large doses (5)
Problem: Expression of doses such as 1,000,000,
100,000, and 1,000 can cause confusion and result in serious
dosing errors, especially if commas are missing or misplaced
(e.g., 1000000, 100000, 1000).
Recommendation: Because words exhibit more distinguishable
characters than numbers, use a combination of both numbers
and words (e.g., 1 million, 100 thousand, 1 thousand)
when expressing large doses. Avoid abbreviations, such
as M for million and K for thousand, which can be ambiguous.
- Tragic errors with concentrated morphine solutions
Problem: Concentrated forms of oral morphine solution
have often been confused with the standard concentration,
leading to serious errors. An elderly man died after receiving
100 mg of ROXANOL (concentrated morphine solution) instead
of the prescribed 5 mg. Accidental selection of the wrong
concentration, and prescribing/labeling the product by
volume, not milligrams, contributes to these errors.
Recommendation: Dispense concentrated oral morphine
solutions only when ordered for a specific patient (not
as unit stock). Affix an auxiliary label to concentrated
solutions to avoid confusion with standard concentrations.
Always prescribe or dispense liquid medications with the
dose specified in milligrams. Educate staff about errors
and develop guidelines for safe use.
- Practitioners speak up about intimidating behavior
Problem: In a recent ISMP survey with over 2,000
respondents, almost 90% reported that they have encountered
intimidating behavior in the last year. Only 39% of respondents
felt that their organizations had dealt effectively with
Recommendation: Define intimidation and create
a code of conduct that outlines unacceptable behaviors.
Survey staff about intimidation and hold frank discussions
about the survey results to open the dialog. Establish
a standard assertive communication process for use among
healthcare providers who must convey important information.
Teach staff a conflict resolution process to ensure patient
safety in the face of disagreements. Encourage confidential
reporting of intimidating behavior and enforce zero tolerance.
III. Drug labeling, packaging, and nomenclature
- BICILLIN C-R (penicillin G benzathine and penicillin
G procaine) and BICILLIN L-A (penicillin G benzathine) (6)
Problem: Over 300 patients at a clinic were treated
for syphilis using Bicillin C-R (which is not effective
for this indication) instead of Bicillin L-A. Similar
product names, packages, and labeling contributed to the
Recommendation: Prevent mix-ups by adding reminders
in computer systems and on storage shelves/package labels,
and reviewing the pharmacy processes for receipt and storage
- Avinza (morphine extended release) and Evista (raloxifene)
Problem: A handwritten order for Avinza 60 mg
was misinterpreted as Evista. The error was discovered
after the physician increased the Avinza dose to 90 mg
when the patient's pain continued.
Recommendation: Add an alert to the pharmacy computer
system for this new look-alike name pair. Always match
the patient's diagnosis to the prescribed medication before
dispensing and administering a drug.
- WELLBUTRIN (bupropion) XL and SR (1)
Problem: A psychiatrist ordered Wellbutrin XL
300 mg. The pharmacist was not aware of the new formulation,
so he misinterpreted the poorly written order and dispensed
two Wellbutrin SR 150 mg tablets for each dose.
Recommendation: Inform staff about the different
Wellbutrin formulations and dosing schedules. Warnings
on pharmacy computers and pop-up alerts can also minimize
- Carpuject syringe mix-ups and potential for tampering
Problem: Since conversion to a needleless system,
Abbott's Carpuject syringes all have a Luer tip with an
identical green cap and look-alike labels. Numerous syringe
mix-ups between potentially harmful products (e.g., ketorolac,
heparin, digoxin, opiates) have been reported. Switching
opiate syringes with other syringes (e.g., promethazine)
for the purpose of diversion has also been reported, despite
packaging in a tamper-resistant SLIM-PACK.
Recommendation: The manufacturer is currently
in the process of enhancing the labels on Carpuject syringes.
Until then, consider using auxiliary labels to differentiate
problem products. To minimize tampering, ask nurses to
inspect the drug name on each syringe (not just the bottom
or top of the sealed tubes) during narcotic counts. Assure
that Carpujects are stored in their original carton in
a way that label panels can easily be read.
- DuoFit XYLOCAINE (lidocaine) ampuls (3)
Problem: After a patient complained of burning
during a potassium infusion, a physician wrote an order
to add lidocaine to each 250 mL bag. The nursing supervisor
retrieved what she thought were 1 mL ampuls of 1% Xylocaine
(10 mg per ampul), but she actually picked up 10 mL Polyamp
DuoFit Xylocaine ampuls (100 mg per ampul), in part related
to poor visibility of the labels on these plastic ampuls.
The patient received 500 mg of lidocaine.
Recommendation: To improve label visibility, leave
Polyamp DuoFit Xylocaine ampuls in their overwrap until
needed. Reassess the need for storing 10 mL vials of lidocaine
in night cabinets, as well as the risks and benefits of
adding lidocaine to bags of potassium chloride. In cases
where this is warranted, have the pharmacy (when available)
prepare the solution.
- Infliximab (REMICADE) and rituximab (RITUXAN) (3)
Problem: An order for infliximab 500 mg IV every 6 weeks
was misinterpreted and rituximab was actually dispensed
and administered. Both drugs are monoclonal antibodies and
doses could possibly overlap.
Recommendation: Include both the brand and generic
names for these products, along with the indication, on
handwritten and pre-printed orders, and on pharmacy-applied
labels. Require an independent double-check before dispensing
and administering either product.
- PROTONIX (pantoprazole) and protamine (6)
Problem: Recently, two cases of confusion between
Protonix and protamine were reported. Both errors were
detected, so neither patient received the wrong medication.
But considering the nature of the medications, serious
harm could have resulted.
Recommendation: Add a look- and sound-alike alert
to the pharmacy computer system, and on automated dispensing
cabinet screens if the products are stored there. Always
match the patient's diagnosis to the medication before
dispensing or administering medications.
HEMOCCULT Sensa (4.2% hydrogen peroxide, 80% denatured
ethyl alcohol) and eye drops (4)
Problem: The wife of a hospitalized patient accidentally
administered Hemoccult Sensa into her husband's eyes.
The bottle had been left at the bedside, and it looked
similar to the patient's artificial tears solution.
Recommendation: Never leave developer solutions
in areas where they can be confused with ophthalmic products
(including patient rooms, bathrooms, and medication storage
areas). Secure these products in a soiled utility room
and confirm the safe storage of developer solutions periodically.
IV. Drug distribution, pumps, and computers
- Potassium chloride error harms child (6)
Problem: A homecare pharmacy dispensed a syringe
containing concentrated potassium chloride for a mother
to add to her child's TPN after a prescribed increase
in the potassium content. The mother confused the potassium
syringe with a saline flush and administered it IV push.
The child arrested and was resuscitated, but suffered
Recommendation: Send only a 2-3 day supply of
TPN to homecare patients when therapy is initiated. Return
the TPN and have pharmacy add the required electrolytes
if changes are made in the prescription.
- Errors during refill of implanted Medtronic pump
Problem: FDA received reports of fatal overdoses
caused by accidental intrathecal injections of concentrated
morphine while refilling implanted Medtronic SynchroMed
infusion pumps. The medication had been intended for the
pump's reservoir. A template was available in a refill
kit to locate the reservoir port, but a similarly packaged
catheter access kit was used instead.
Recommendation: If you use or plan to use these
devices, conduct a failure mode and effects analysis to
determine error potential. Create standardized order sets
for refilling the pumps and include the applicable refill
kit number. If possible, use devices with only a reservoir
port, not a catheter access port. If pumps with catheter
access ports are necessary, keep the catheter access kits
separated from the refill kits.
Testing the computer on "live" patients
Problem: While testing a pharmacy computer system,
an information technology staff member entered an amoxicillin
order for a "live" patient with an amoxicillin
allergy. The drug was dispensed and administered to the
patient, who developed toxic epidermal necrolysis.
Recommendation: Avoid granting access to live
patient profiles to anyone other than pharmacy staff.
Use only "test" patients when evaluating the
pharmacy system or for demonstration purposes.
The ISMP Quarterly Action Agenda is now
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