ISMP Quarterly Action
Agenda - January-March 2005
From the April 7, 2005 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 items appeared in the ISMP Medication Safety Alert! between January and March 2005. Each item
includes a 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 can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education
credit is available for pharmacists and nurses.
I. Issues Related to Communication
of Prescribed Medications
II. Issues Related to Labeling, Packaging,
- Mistaking mg for mL when dosing units are not specified
Problem: A pharmacist asked a technician to quickly
prepare "morphine point one five, six syringes"
for a neonate, but each syringe was filled with 0.15 mL
(0.3 mg), not 0.15 mg (0.075 mL) as intended. The pharmacist
caught the error, but in another case, a toddler died
after receiving 0.8 mL (8 mg) of oral morphine instead
of 0.8 mg based on a verbal order that did not include
the dosing units.
Recommendation: When accepting a verbal order
or instructions to fill a stat medication order, be sure
the information is complete (including dosing units),
write it down, and verify its accuracy by reading it back
to the originator. In the pharmacy, prepare all (including
stat) medications using the order copy and label rather
than verbal instructions.
- Joint Commission and error-prone abbreviations (3)
Problem: Requiring pharmacists and nurses to clarify
all orders containing error-prone abbreviations has resulted
in interdisciplinary friction. Thus, the Joint Commission
will no longer consider organizations compliant even if
pharmacists or nurses call a prescriber for clarification
Recommendation: Assign full responsibility of
prescriber compliance for avoiding error-prone abbreviations
to the medical staff. Ensure that nurses and pharmacists
support educational efforts and avoid using error-prone
- Handling "hold" orders (6)
Problem: Warfarin was placed on hold before an
endoscopy, but not resumed after the procedure. The patient
suffered a stroke 6 days later. An order to hold a medication
can also result in resuming the medication too soon.
Recommendation: If a patient is on daily medications
based on lab results, the pharmacy profile and nursing
MAR should reflect this as an ongoing active order listing
the drug, route, and frequency, with a notation that a
dose must be prescribed each day. If medication doses
are not guided by daily lab values, hold orders should
not be accepted unless they include specific instructions
for when to resume the medication. However, all medications
held for a procedure should be rewritten fully after the
- CAMPATH (alemtuzumab) label changes (1)
Problem: Campath packaging includes three 30 mg
(10 mg/mL) ampuls in one carton, but just one ampul is
needed for a typical dose. A technician thought the entire
carton contained 30 mg and prepared a 90 mg dose by mistake.
Recommendation: A new 30 mg/mL concentration is
now being packaged in single vial cartons according to
the manufacturer, Berlex Laboratories. Be sure to isolate
the old concentration from stock, make the necessary changes
in the pharmacy computer, add directions for admixture,
and notify staff about the change.
- Phenylephrine mistaken for metoclopramide (2)
Problem: A patient undergoing surgery inadvertently
received phenylephrine 10 mg IV instead of metoclopramide
after a look-alike phenylephrine vial was retrieved from
a metoclopramide bin. Similar instances of misplaced vials
had been encountered before at this hospital, but widespread
action had not been taken to reduce errors with these
and other look-alike products.
Recommendation: Standardize the organization of
anesthesia carts and store similar-looking vials away
from each other. Consider attaching a bag of diluent to
phenylephrine vials to further differentiate it from metoclopramide.
- Brand name extension with KAOPECTATE (bismuth subsalicylate)
Problem: The brand name, Kaopectate, is now being
used for two products with different ingredients: a well-known
anti-diarrhea agent and a stool softener (docusate calcium).
Recommendation: Alert staff and patients that
there are now two Kaopectate products, each for opposing
indications. Verify the drug's indication if Kaopectate
GLUCAGEN (glucagon) bar code could cause errors
Problem: Glucagen is packaged as a vial of lyophilized
powder (1 mg) and a separate vial of sterile water for
reconstitution (1 mL). Each vial is labeled with the same
bar code. If the diluent is scanned, a hypoglycemic patient
could receive water instead of active drug.
Recommendation: Warn practitioners of the risk
of errors if you use a bedside bar-coding system. Currently,
defacing the bar code on the diluent vial is the only
way to eliminate the risk of error.
- Atropine and adenosine vial mix-ups (5)
Problem: Vials of atropine 0.4 mg/mL and adenosine
6 mg/2 mL from Baxter can easily be confused due to similar
Recommendation: Segregate these vials and affix
auxiliary labels if both must be available in the same
- Drug product confusion in the sterile field (5)
Problem: Ethyl alcohol from an unlabeled basin
was drawn into a syringe and injected into a patient's
face instead of lidocaine, which was also in an unlabeled
basin. The patient suffered partial facial paralysis.
Recommendation: Develop and implement policies
and procedures for safe labeling of all medications and
solutions within sterile fields (including in the ED,
radiology, and cardiac catheterization labs).
III. Issues Related to Drug Information,
Storage, and Standardization
- ABRAXANE (paclitaxel protein-bound particles for
injectable suspension) and TAXOL (paclitaxel) (5)
Problem: Abraxane, a new solvent-free formulation
of paclitaxel that does not require premedication with
corticosteroids and antihistamines, is typically dosed
at 260 mg/m2 every 3 weeks. If confused with conventional
paclitaxel, which is dosed at 175 mg/m2 every 3 weeks,
harm could result.
Recommendation: Be sure oncology staff are aware
of the error potential with this new drug. Ask oncologists
to include the brand name if prescribing Abraxane, and
distinguish it from conventional paclitaxel on computer
screens (e.g., refer to Abraxane as "nanoparticle-paclitaxel").
- Safety challenges with DEPODUR (morphine sulfate
extended-release liposome injection) (3)
Problem: DepoDur is a new one-time extended-release
epidural injection that provides pain relief for about
48 hours. Safety challenges with this drug include: (1)
identifying patients who have received DepoDur to prevent
administration of additional pain medications and ensure
proper monitoring, and (2) potential confusion with DURAMORPH
(morphine sulfate, preservative free).
Recommendation: Implement preprinted orders for
DepoDur that include documentation of the time and date
of injection, appropriate monitoring parameters, and bold
warnings that the patient should not receive other pain
medications, CNS depressants, or any epidural drugs. (Removal
of the epidural catheter after administration of DepoDur
helps ensure this.)
- Safety is a team effort (1)
Problem: Maintenance staff filled empty detergent
containers with used hydraulic fluid, which was later
used to wash thousands of surgical instruments.
Recommendation: Never reuse medical containers.
Include all non-professional healthcare workers in patient
safety efforts and ensure that they recognize the many
safety hazards that are under their control. (Visit our online store for information on a video, Patient Safety Requires a
Team Effort, with vignettes that show how non-clinical
employees can unknowingly play a role in a medication-related
- Joint Commission, the Rule of 6, and the Broselow
tape (4, 6)
Problem: A calculation error related to the Rule
of 6 may have contributed to an infant's death recently
when it led to a misplaced decimal point and the preparation
of a dopamine infusion 10 times more concentrated than
required. Unrelated to this event, use of the Broselow
tape is another source of nonstandard concentrations,
which also does not comply with the Joint Commission National
Patient Safety Goal.
Recommendation: Establish standard concentrations
for pediatric critical care drugs and abandon use of the
Rule of 6. In future revisions, the Broselow tape will
only provide dosing information for IV push medications.
However, continue to use the tape for pediatric emergencies
until standard concentrations have been established in
your facility. The Joint Commission is considering our
suggestion to allow hospitals a sufficient amount of time
for transitioning to standard concentrations during pediatric
emergencies, as was granted to hospitals that used the
Rule of 6.
IV. Other Discussion Items
- Make a commitment to "pro-change" in your
Problem: Only half of hospitals surveyed in the
2004 ISMP Medication Safety Self Assessment for Hospitals
have a convened interdisciplinary team that routinely
analyzes and uses published error experiences from other
organizations to proactively target improvements in the
medication use process.
Recommendation: Assign a specific professional(s)
to research published error reports and new advances in
medication safety. Routinely bring this information to
the current team that reviews internal medication safety
issues to develop an action plan for proactive change
- Survey indicates that formulary myths still exist
Problem: A reader survey shows that myths such
as "The specialist knows best," "The formulary
interferes with clinical freedom," and "Widespread
use equals drug of choice" are still present in today's
Recommendation: Hold frank discussions with the
medical and professional staff about the purpose of the
formulary to dispel common myths and stress its importance
as a crucial safety measure.
- Provide a "sterile cockpit" for critical
healthcare duties (6)
Problem: Distractions cause errors. The airline
industry has addressed this by rigorously enforcing restrictions
in potentially distracting behavior during critical duties.
Recommendation: Provide healthcare staff with
a similar "sterile cockpit" during crucial steps
in the medication use process.
- Measuring medication safety (5)
Problem: Measuring medication safety is fundamental
to improvement, but identifying practical and accurate
methodologies for data collection has long been a problem.
Historically, healthcare has relied on practitioner reporting
of errors, which is highly inaccurate and counterproductive.
Recommendation: Process measures, structure measures,
balancing measures, and outcome measures must be tracked
to improve medication safety. See the full newsletter
article for examples of each type of measure and how to
collect data to demonstrate whether improvement efforts
have been successful.
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