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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - January - March 2006

From the April 20, 2006 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 2006. 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 can also be viewed in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses at:

Scanned and faxed prescriptions (6)
Problem: During scanning, a number and decimal point were cut off from the margins of an order, which led to dosing errors with gentamicin and milk of magnesia. Similar problems have occurred with faxed orders.
Recommendation: Order forms and prescriptions should have margin lines to indicate areas beyond which writing is not permissible. Prescribers should be made aware of the risk when writing orders or notes outside the margin lines, citing actual errors described in the newsletter.

Edetate calcium disodium (CALCIUM DISODIUM VERSENATE) and edetate disodium (3, 6)
Problem: A 5-year-old autistic boy died after he was given edetate disodium instead of edetate calcium disodium during chelation therapy. Both drugs are commonly referred to as "EDTA." CDC has also alerted practitioners about the risk of confusion, citing multiple deaths associated with hypocalcemia during chelation therapy.
Recommendation: CDC recommends evaluating the need to keep edetate disodium on the hospital formulary. If both drugs remain on the formulary, affix auxiliary labels to the packages of each drug to remind staff about the need to match the drug to the patient's diagnosis. Reminders about potential confusion should appear on the computer screen whenever processing these orders. When appropriate, remind prescribers that the American Academy of Pediatrics strongly discourages chelation therapy as a routine intervention in autistic children.

IV vincristine (4)
Problem: Findings from an ISMP survey suggest that widespread application of relatively simple error reduction strategies are still needed in all settings to avoid further tragic deaths from inadvertent intrathecal administration of IV vincristine.
Recommendation: Review the findings of the survey, and implement the following safety measures: (1) dilute the drug before dispensing it; (2) place doses in distinctive packaging and affix special warning labels [FOR IV USE ONLY]; (3) deliver IV vincristine to locations where intrathecal drugs are prohibited; and
(4) give intrathecal and IV medications at different times and require pharmacy to confirm that the intrathecal medications have been given before dispensing the IV vincristine.

Resolving drug safety conflicts (1)
Problem: Doses of some medications need to be adjusted when converting from one route to another. Textbook and label warnings about this are often inadequate or nonexistent. In one case, a nurse and pharmacist intervened when a physician ordered metoprolol 50 mg IV, which led to a conflict between the practitioners. The nurse and pharmacist persisted and the physician decreased the dose, averting serious patient harm.
Recommendation: Establish a clear process for resolving drug therapy conflicts, which concludes only when all are satisfied that no harm will come to the patient. Request supporting documentation for atypical orders. Nurses and pharmacists should refuse to dispense or administer a medication if they are reasonably sure that withholding the drug is safer than giving it. Refer unresolved safety issues to an ad-hoc group for peer review. 
Confusion over meaning of color-coded wristbands (5)
Problem: Practitioners at an ambulatory diagnostic center were unaware that a green bracelet on a hospitalized patient signified a latex allergy. Thus, the patient's tests were performed using latex-containing vials/syringes, resulting in a reaction. A survey of Pennsylvania healthcare facilities confirmed that wide variations of colors are used to communicate information via wristbands.
Recommendation: Standardize and limit the number of primary colors used for wristbands and include brief, preprinted, descriptive text on the band for clarification of its intent.  

Double key bounce and double keying errors (1)
Problem: Errors have resulted from pressing once on an infusion pump's number key and getting an unintended repeat of that same number (e.g., the pump records 366 mL per hour, not 36 as intended). This occurs when the key is softly or partially pressed for a time, as one might do if programming a pump from an odd angle. Double keying errors from accidentally hitting a number key twice have also resulted in errors.
Recommendation: Always compare the patient's prescribed therapy on the medication administration record to the displayed pump settings. Stand directly in front of the pump when programming it and listen for one beep to correspond with each number programmed. Require an independent double check of pump settings for selected high-alert medications. Use smart infusion pumps with dose-checking technology.

Programming codes (5)
Problem: Problems with programming codes can cause unintended consequences in application software. For example, a "code bug" with ABACUS TPN Software allowed continuation of vitamin K on a system-generated compounding sheet, after the additive had been discontinued.
Recommendation: Practitioners should ask current and prospective information system software vendors how they notify users of software problems and how such information can be retrieved. Software vendors should actively disclose when code issues are discovered if they can affect patient safety.

ROZEREM (ramelteon) and RAZADYNE (galantamine) (2)
Problem: Community pharmacists have reported confusion between a new sleep aid, Rozerem, and Razadyne, a drug for Alzheimer's disease. Both medications are available as 8 mg tablets. Razadyne is also new to the scene as a name change from REMINYL.
Recommendation: When patients who take either of these drugs are admitted to the hospital, appropriate precautions should be taken to avoid confusion. Match each drug to the patient's condition before dispensing or administering it. Warn patients who are taking either medication about the potential for mix-ups.

Lithium dosed in mg or mEq (4)
Problem: A physician prescribed lithium 100 mg daily. The only dosage form to accommodate that dose was lithium citrate syrup. The pharmacist failed to notice that the dosage for the syrup was in mEq (8 mEq/5 mL). He mistakenly entered and dispensed 100 mEq (3,750 mg/62.5 mL) of lithium. The patient required transfer to a critical care unit.
Recommendation: Maximum dose alerts during order entry should be available for lithium, especially since dosing units may not be as expected. Suspect an error if the volume of liquid medication needed for each dose seems unusually high.

New form and strength: KALETRA (lopinavir/ritonavir) (4)
Problem: A new tablet formulation of Kaletra contains lopinavir 200 mg and ritonavir 50 mg; the old capsules contain lopinavir 133.3 mg and ritonavir 33.3 mg. A pharmacist, who assumed that just the dosage form had changed, dispensed Kaletra tablets to a patient who had been taking the capsules, without adjusting the dose.
Recommendation: Since there is no mention of the dosage change on the tablet product container, affix an auxiliary label to the containers of both the capsule and tablet dosage form for reference. Advise patients who are taking this drug about the potential for dosing errors.

Category X drug TRACLEER (bosentan) (5)
Problem: A pregnant nurse was splitting a tablet of Tracleer for a pediatric patient when she learned that it's a pregnancy category X drug, which may adversely affect a fetus. Current labeling information contains no warnings about crushing or splitting tablets, and no special handling instruction for healthcare personnel. 
Recommendation: According to the manufacturer, pharmacy staff should prepare Tracleer doses that require cutting by using a commercial pill cutter, and then safely repackaging, labeling, and dispensing the drug to the patient care unit. Another option is to have pharmacy dissolve the medication in water (without crushing the tablets first) and measure the needed dose. The manufacturer has been asked to include special handling information in its labeling so organizations can formulate safe handling policies.

Patient safety brochures (2)
Problem: Findings of a recent analysis suggest that safety brochures for patients may not be as useful as intended unless the content and tone are appropriate, and the messages are reinforced.
Recommendation: Assess the content of current patient brochures on safety. Ensure that safety tips are well defined and prioritized, and that the basis for each tip is provided. Confirm that the brochure tells patients how to report risks and errors. Ensure that the tone does not shift responsibility for patient safety solely to the patient by describing what the healthcare organization is also doing to ensure his safety. Encourage staff to reinforce the safety messages frequently.

Harmful errors in radiology (2)
Problem: According to USP's MEDMARX database, 12% of the 2,032 errors that occurred in radiology, nuclear medicine, and cardiac catheterization suites between 2003-2004 resulted in harm. This rate of harm is about seven times the percent of harm reported in all other care locations tracked by the database.
Recommendation: Thoroughly examine medication use processes in radiology areas to uncover risks that could lead to harmful errors. Reduce these risks with well designed protocols, safe storage of medications, properly trained staff to administer medications, available nurses to monitor patients when possible, readily available antidotes, and other measures. 

Tips for increasing error reporting (3)
Problem: A nurse discussed a serious dosing error she had made with the patient's physician, but was unwilling to report it to her manager due to fear of reprisal. Error reporting is a fundamental component of learning, but it may be challenging to persuade healthcare workers to submit reports unless a culture of safety exists.
Recommendation: To improve reporting, the following characteristics are crucial: (1) the process must be clear and easy while detailed enough to get causative information; (2) those who receive reports must be trustworthy and just, keep the identities of reporters and involved workers confidential, and provide feedback about how the information will be used; and (3) expectations for reporting should be included on job descriptions and performance evaluations. 

Adverse drug reaction: IV lorazepam infusion and propylene glycol toxicity (3)
Problem: An intubated patient was sedated with a continuous infusion of lorazepam. The infusion rate escalated over several days to 8 mg/hour. The patient subsequently developed propylene glycol toxicity, marked by acute renal failure and metabolic acidosis, secondary to the continuous lorazepam infusion.
Recommendation: When administering continuous high doses of IV lorazepam, frequently assess the patient's acid-base status and renal function. Measure serum osmolarity, electrolyte levels, and osmolal gap daily. Consider adding a synergistic opiate to allow for administration of a lower lorazepam dose. Increase staff awareness of the risk of toxicity.

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.

Access the CE for Pharmacists
(CE Expired)
This quarter's continuing education exam covers materials included in the ISMP Medication Safety Alert dated Apr 20, volume 11, issue 8

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses


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