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ISMP Quarterly Action Agenda -January-March 2010

From the April 8, 2010 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 2010 issues of the 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 viewed in the ISMP Medication Safety Alert! section of our Web site. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

Improperly designed order sets can lead to errors (5)
Problem: ISMP advocates the use of standard order sets to minimize incorrect or incomplete prescribing, standardize patient care, and ensure clarity when communicating orders. However, if standard orders are not carefully designed and maintained to reflect best practices and ensure clear communication, they may contribute to errors. Frequently observed problems involve incorrect, outdated, ambiguous, or contraindicated content; format issues; and failure to approve and update the order sets. Examples can be found at:
Recommendation:  ISMP has created Guidelines for Standard Order Sets in the form of a checklist (, which can be used by interdisciplinary teams to evaluate all current orders sets and design new order sets. The guidelines pertain to written and electronic order sets.

v Epidural bupivacaine and fentaNYL given intravenously leads to death (5)
Problem: In 2006, a 16-year-old pregnant patient at a Wisconsin hospital was tragically given an infusion of epidural bupivacaine and fentaNYL intravenously. Following the incident, which led to criminal charges for the nurse involved, the hospital invited ISMP to conduct an independent root cause analysis of the event, which identified four proximate causes and dozens of underlying system causes and performance shaping factors that led to the tragic event.
Recommendation:  In cooperation with hospital leadership, the analysis appears in the April 2010 issue of The Joint Commission Journal on Quality and Patient Safety. Full text of the article is available free at: Healthcare organizations are encouraged to review the analysis to identify similar potential failure points in their own systems and implement recommended risk-reduction strategies.

vErrors with insulin  (5)
Problem: In events reported to the Pennsylvania Patient Safety Authority involving insulin products, 52% have led to situations in which a patient received the wrong dose of insulin or had a dose of insulin omitted.
Recommendation: To identify and monitor problems associated with insulin, the Authority has posted a sample tool on its Web site: Consider utilizing this tool to document facility-specific process and outcome measures involving the use of insulin.

 v Wrong concentration of IV insulin infusion (3)
Problem: A new nurse in the emergency department helped a busy colleague by preparing an insulin infusion in a 5 units/mL concentration, following instructions in the drug reference attached to the dispensing cabinet. But the hospital’s standard concentration for insulin infusions was 1 unit/mL. Although the bag was properly labeled, the concentration was not reviewed during handoff to the receiving nurse, who started the infusion according to the hospital’s standard concentration.
Reccomendation: Ideally, pharmacies should prepare infusions that are not commercially available. When 24-hour pharmacy coverage is not an option, or under conditions that warrant immediate use, up-to-date hospital-approved drug guidelines for IV admixtures prepared by nurses should be readily available, and nurses should be educated about the procedures. Nurse-prepared infusions, especially with high-alert drugs, should be independently checked after preparation and during handoffs.

vBaclofen programming error with SynchroMed II pump (2)
Problem: A patient was hospitalized after receiving a significant overdose of intrathecal baclofen. The patient’s physician had accidentally programmed a Medtronic SynchroMed II implantable pump to administer an extra dose every hour rather than every morning. Medtronic had previously distributed a letter via its sales force to warn about programming errors and announce software modifications. The letter had not reached the physician, and software modifications had not been provided.
Recommendation:  If your inpatient or outpatient providers care for patients with SynchroMed pumps, please check that the latest software updates for the N’Vision Clinician Programmer have been received. How-ever, do not rely on the updates alone to prevent errors. The total dose and percent of change from the prior dose are visible on a summary screen, but there is no alarm or stop feature for critically high or low doses. An independent double-check to ensure accurate programming is needed. Advise emergency department staff to consider an error if patients with implantable pumps report a recent refill or programming change.

vMix-up between vecuronium and valproate sodium injections in the pharmacy (1)
 Two minibags were accidentally prepared with vecuronium instead of valproate sodium injection. Both medication vials were nearly the same size with red caps and had been stocked close to one another in the pharmacy. The patient was able to alert the nurse when it became difficult to breathe, and the infusion was stopped. 
Recommendation: Sequester neuromuscular blockers in a secure, lidded bin (or a separate, lidded dispensing cabinet compartment) labeled “Paralytic Agent” in the pharmacy and any patient care locations where needed (e.g., ED, PACU, ICU). Some hospitals also apply a ShrinkSafe sleeve to the vials to warn about the drug’s paralytic nature; how-ever, use on multiple neuromuscular blockers can make them look similar and contribute to mix-ups. Minimizing the variety of neuromuscular blockers will help reduce similarity in appearance (with or without the sleeves).

vADEs with rosiglitazone (AVANDIA), QUEtiapine (SEROQUEL, SEROQUEL XR), and testosterone gel (4)
During the 3rd quarter of 2009, ISMP’s Quarter-Watch identified adverse drug events (ADEs) frequently reported to FDA. Rosiglitazone ranked highest with more than 1,000 reports of patient deaths, reinforcing concerns about its cardiovascular safety. QUEtiapine ranked second with 977 reports of serious or fatal events, caused mostly by a link between the drug and development of diabetes. Despite FDA warnings about off-label use of testosterone gel in women and accidental exposure to children, 155 reports were received involving exposure to women and 22 reports involving children.
Recommendation: If patients are discharged on rosiglitazone, alert them to cardiovascular risks and symptoms to report to their doctor. Advise diabetic patients discharged on QUEtiapine to monitor their blood glucose closely, and patients without diabetes to report signs of diabetes to their doctor. If using testosterone gel upon discharge, patients should be reminded to keep the application site covered, wash their hands after application, and to be cautious around pregnant women.

 Designing a Medication Error Reduction Plan (MERP) (6)
To reduce medication errors, every hospital in California (CA) was required to implement a MERP approved by the CA Department of Public Health by January 2005. Essential features of the MERP include assessing, improving, and evaluating medication safety. CA hospitals are also required to incorporate and learn from external medication-related errors and take action to prevent them.
Recommendation:  ISMP encourages hospitals outside of CA to consider adopting a similar program to significantly impact patient safety. Details regarding the required components of the MERP in CA along with self-assessment questions for evaluation of the plan can be found at:

 Drug name mix-up between levetiracetam (KEPPRA) and levocarnitine (CARNITOR) (3)
Two children received levetiracetam instead of levocarnitine in error after a technician selected the wrong drug from an alphabetical pick-list during order entry. Both drugs have the same elixir strength and are dosed similarly in children. Neither child was harmed, but a patient on levetiracetam could experience a seizure if given levocarnitine in error.
Recommendation:  Use both brand and generic names when prescribing these drugs, along with the indication. Add these to your list of look-alike drug names and build software alerts to warn about confusion. Another strategy is to change levocarnitine to L-carnitine in drug databases, or take other measures to differentiate these drugs in pick-lists.

e-Rx error caused by a truncated/broken word (6)
 Space ran out on the first line of directions when entering an electronic prescription that printed in the pharmacy, and the word “until” was split on the prescription so that the “l” appeared on the next line. A technician mistook the letter l as the number 1, which altered the directions for duration of therapy from “7” days to “17” days.
Recommendation:  Check your electronic systems to determine if words or numbers truncate/break onto different lines, potentially causing a problem on screens, labels, and MARs. If you identify problems, alert your vendor and send ISMP examples through our Medication Errors Reporting Program (MERP)  (

Carton may hold multiple lot numbers and expiration dates (5)
PharMEDium shipped ropivacaine in sodium chloride in a carton that contained CADD cassettes with 3 different lot numbers and expiration dates. The pharmacy technician assigned the same expiration date to all the cassettes while loading them in a dispensing cabinet. Products from other outsourcing companies have also been shipped in this manner.
Recommendation:  Educate pharmacy staff regarding the potential for products with different expiration dates to be shipped in the same carton. ISMP recommended to outsourcing companies that a more prominent auxiliary label be placed on the outer carton if products with differing expiration dates if they are shipped together.

Ambiguous and dangerous abbreviation “UD” (1)
 The rate of infusion for an IV diltiazem solution was unknown, so a pharmacist selected “UD” (ut dictum or “as directed”) from a drop-down list to populate the rate field. The nurse thought “UD” meant “unit dose” and ran the infusion at 125 mg/hour. Nurses polled after the event also thought UD meant unit dose. The patient died after receiving the infusion.  
Recommendation:  The Latin abbreviation “UD” should not be used as it is too easily confused with “unit dose.” Consider requesting that your computer system vendor eliminate the ability to enter “UD” in the rate field. Prescribers should provide complete orders; pharmacists should clar-ify incomplete orders.

 Look-alike Sandoz ADD-Vantage antibiotics (6)
Ampicillin 2 g and nafcillin 2 g ADD-Vantage containers from Sandoz look nearly identical.
Recommendation:  If you use ADD-Vantage antibiotics in your facility, circle or highlight the drug name on the container to draw attention to it. Consider purchasing one of these products from a different manufacturer.

Removing inaccurate allergy information from electronic records  (2)
During hospitalization, “vitamin D” was erroneously entered into the allergy field of a patient’s medical record. On subsequent visits, the erroneous information remained in the record. Practitioners in clinical areas could not correct the medical record; only an IT programmer could make the correction.
Recommendation: Clinicians and IT staff should be educated regarding their organization’s process for correcting electronic information. This process should be streamlined and standardized as much as possible without jeopardizing the integrity and security of electronic information.

Inaccurate measurement is possible when using certain Baxa oral syringes  (4)
Certain Baxa oral syringes make it difficult to measure doses. For example, the the 5 mL amber oral syringe marks 1/4 teaspoon at 1.2 mL instead of 1.25 mL. And some numbers on the 3 and 5 mL clear plastic oral syringes do not align with the correct calibration markings. The problems have been addressed, but wholesalers may still be shipping these problematic syringes.  
Recommendation: Assess your supply of oral syringes and inform nurses about these issues if you have affected syringes. Advise practitioners to measure doses in mL due to the misalignment of the teaspoonful markings. Consider seeking inventory from another manufacturer temporarily, although there may be limited options due to the national shortage of oral syringes.


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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