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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - january - march 2009

From the April 23, 2009 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 items from the January-March 2009 ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP List of High-Alert Medications. The Action Agenda is also available for download in a Word format ( that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Many product-related problems can also be visualized in the ISMP Medication Safety Alert! section of our website at:

Key: v  — ISMP high-alert medication

Acutecare New Agenda Hed (1)
Problem: Mead Johnson Nutritionals did little to inform the public or healthcare providers about changing the Fer-In-Sol concentration from 15 mg of iron/0.6 mL (25 mg/mL) to 15 mg of iron/mL. The old and new packages are identical except for a brief note about the new concentration on the new product carton. Iron drops from other manufacturers still use the 15 mg of iron per 0.6 mL concentration.
Recommendation:  Stock a standard concentration of iron drops, and be sure the formulary and drug indexes list the correct concentration. Require all orders to be written in mg, never by volume alone. Always verify the concentration of iron in the product being dispensed and administered as well as the volume needed to provide the intended dose.

v Reuse of insulin pen for multiple patients risks transmission of bloodborne diseases (3,6)
Problem: An Army hospital announced that 2,114 insulin-dependent diabetic patients may be at risk for developing a bloodborne disease because insulin pens were reused for multiple patients. Although a new needle was placed on the pens before each use, cross-contamination is still possible. FDA followed with an alert reinforcing that sharing insulin pens may result in transmission of bloodborne diseases.
Recommendation:  Facilities using insulin pens should act immediately and provide education and continuous monitoring to prohibit situations where an individual patient’s pen might be reused for another patient. Labeling each dispensed pen with the patient’s name may help reinforce that the pen is intended for that patient alone. If institutional safety with pen devices can’t be assured, they shouldn’t be used.

vBeware of basal opioid infusions with PCA therapy (5)
Problem: An opioid-naïve patient with sleep apnea was started on HYDROmorphone PCA with a basal infusion. She experienced respiratory depression and became unresponsive. The PCA order form prompted for a basal infusion without screening for appropriate candidates. The American Pain Society cautions against using continuous basal infusions because studies have failed to demonstrate significant differences in the quality of analgesia with or without basal infusions.
Recommendation: Establish risk factors and screening criteria for basal infusions and avoid their use for patients with sleep apnea and patients who are not opioid-tolerant (patients who have received opioids regularly for 7 or more days). Establish special monitoring requirements (e.g., pulse oximetry/capnography, frequent assessment in the first 24 hours and at night) for any patient who receives a basal infusion.

vFatal outcome after inadvertent injection of topical (6)
Problem: A patient died after receiving an injection of EPINEPHrine 1:1,000 from an unlabeled syringe that a surgical nurse and surgeon thought contained a local anesthetic. EPINEPHrine for topical use was on back-order, so the nurse withdrew the contents of a vial of the injectable product into a syringe. The syringe was mistaken as the local anesthetic.
Recommendation: Supply EPINEPHrine for topical use only in the manufacturer’s or pharmacy-prepared pour-bottles. Never withdraw a topical product into a parenteral syringe. Use auxiliary labels to draw attention to “TOPICAL” use only. Keep local anesthetics for injection in their original vials until ready to use. Label all syringes. Use presoaked EPINEPHrine pledgets when feasible.

vMethotrexate overdose (6)
Problem: Before hospital admission, a patient with rheumatoid arthritis had been taking oral methotrexate 10 mg BID once weekly on Mondays. On the discharge medication list, the drug was erroneously transcribed as “methotrexate 10 mg po BID.” The patient took the drug daily using her current prescription supply at home and had to be readmitted for treatment of serious side effects.
Recommendation: Before discharging patients, medications on the discharge list should be reconciled with the list provided upon admission, and discrepancies should be resolved. Patient education should emphasize the weekly dosing schedule and, to ensure understanding, patients discharged on methotrexate should receive follow-up phone calls a day or two after discharge.

ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)(3)
As with any technology, there are benefits and risks associated with ADC use. In 2007-2008, ISMP convened a national forum of stakeholders to develop interdisciplinary guidelines for promoting safe practices when employing ADC technology. Some factors that influence ADC safety include: interconnectivity with the pharmacy computer; pharmacist review of orders before removing drugs; use of overrides; screen display of patient and drug information; and quantity of stock.
Recommendation: If your organization uses ADCs, form an interdisciplinary team to review the guidelines (, listen to a recent webcast about ADC safety (, and complete a new ADC self-assessment that will soon be available on the ISMP website.

vAre 40,000 unit vials of heparin really needed? (1)
The total content in 4 mL vials of heparin (10,000 units/mL) may be mistaken as 10,000 units, not 40,000 units. The total volume is easily missed on the label. Errors could result in a serious overdose.
Recommendation: Evaluate if your facility needs heparin vials that contains 40,000 units. When possible, stock only a 1 mL vial of heparin 10,000 units/mL.

Topical lidocaine gel and mammography (5)
Shortly after the release of findings from a study that used topical lidocaine to reduce discomfort during breast mammography, FDA issued an advisory to remind patients, healthcare professionals, and caregivers about potentially serious hazards—including death—associated with overuse of topical anesthetics.
Recommendation: Warn staff and consumers to use topical anesthetics that contain the lowest possible amount of medication to relieve pain, apply it sparingly on unbroken, non-irritated skin, and avoid wrapping or covering the skin with any occlusive dressing or other material.

Inattentional blindness: What captures our attention? (4)
When someone fails to see what should have been plainly visible—a warning sticker on a medication label, for example—the cause is usually rooted in inattention blindness, a condition all people exhibit periodically. To combat information overload, the brain scans and sweeps until something sticks out to capture its attention. Unfortunately, the brain is a master at filling in gaps and making do, compiling a cohesive portrait of reality based on just a flickering view.
Recommendation: To combat inattentional blindness: 1) increase the conspicuity of critical information on product labels, computer screens, medication administration records, and other sources of information, by using a high degree of contrast with the background; 2) ensure that the critical information you are providing is perceived as relevant by those who need it; 3) decrease multi-tasking and diversion of attention when carrying out complex tasks; and 4) reduce over-reliance on technology.

Confusing nomenclature with valproic acid (4)
Valproic acid is available in various dosage forms and salts, so products can be confused. For example, a patient was supposed to receive DEPAKOTE ER (ordered as “divalproex ER”) but received divalproex “EC” (the enteric-coated form of divalproex). Another product, DEPAKENE, contains valproic acid when it is in capsule form and valproate sodium in liquid form. Valproate sodium is known as DEPACON in parenteral form.
Recommendation: Limit the forms of valproic acid available in the hospital, and educate staff about the different dosing schedules and indications for all formulations that remain. If possible, add a computerized alert to remind staff about the potential for mix-ups. When repeating back oral orders, use full words (e.g., extended release), not abbreviations. Separate storage and use auxiliary warning labels to differentiate the products.

Patch advisory associated with safety during MRIs (5)
FDA issued a public health advisory in March regarding transdermal patches worn during an MRI. Some patches are formulated with an aluminized backing or invisible metal layer that could cause excessive heating and tissue damage to the patient if worn during an MRI.
Recommendation: Hospitalized patients being discharged on a transdermal medication should be educated to remove the patch temporarily when undergoing an MRI. Facilities should follow published recommendations concerning patients who wear patches and undergo MRIs (

Lbs/kg confusion (1)
A pharmacist was consulted to visit a patient for CUBICIN (DAPTOmycin) dosing. The pharmacist noticed that the patient’s weight had been entered into the computer as 150 kg instead of 150 lbs, which equals 68 kg. The person entering the weight failed to convert lbs to kg after weighing the patient on a scale that measured weight in lbs.
Recommendation: Weights should always be based on the metric system, and scales should always weigh in kilograms. It’s important that all preprinted order sets, protocols, guidelines, and computer screens only prompt for kg weights.

REVATIO and VIAGRA are both sildenafil (2)
An emergency department patient with chest pain told the doctor she was taking Revatio for primary pulmonary arterial hypertension. The physician did not know Revatio was sildenafil, the same drug as Viagra, so he treated her with nitroglycerin (sublingual and IV), which is contraindicated.
Recommendation: Health professionals can reduce the risk of errors by reviewing readily accessible drug information if they encounter unfamiliar products. Also encourage patients who take Revatio to note on their medication list that the drug is also marketed as Viagra.

LYRICA (pregabalin) and LOPRESSOR (metoprolol tartrate) mix-up (2)
A patient was admitted to a hospital with an order for Lopressor 100 mg BID. However, the physician’s handwriting was poor, and the order was misinterpreted and dispensed as Lyrica 100 mg BID.
Recommendation: Hospitals may want to add a computer alert about this newly reported look-alike drug name pair. Matching the drug’s indication to the patient’s health condition is the best way to avoid mix-ups between products with look-alike names.

Color-coded eye medications (3,5)
Bausch and Lomb’s atropine sulfate 1% and cyclopentolate 1% ophthalmic drops look nearly identical, which led to an error. Another mix-up occurred between polymyxin B and trimethoprim ophthalmic solution, and neomycin, polymyxin B, and gramicidin solution. Packaging similarities are related to color-coding by pharmacologic class, making all products within a class the same color.
Recommendation: Avoid awarding contracts to one vendor for an entire ophthalmic product line, and purchase products within a class from different manufacturers.

“2day” gets “86’d”   (4)
A pharmacist questioned whether an order for magnesium chloride 64 mg TID “2Day” meant to give the drug TID for 2 days or to give it “today” (2Day). It turned out “2Day” was “text messaging” shorthand for “today.”
Recommendation: Text messaging language is not appropriate for writing or transcribing medical orders due to potential misinterpretation.

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

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