Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook


ISMP Quarterly Action Agenda - january - march 2011

From the April 7, 2011 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 2011 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.

Key: v  — ISMP high-alert medication

vStandard NICU drug concentrations from ISMP and the Vermont Oxford Network (VON) Collaborative (1)
Problem: Standardizing the concentrations of drug infusions has enormous potential for increasing safety, especially with neonatal care. Such efforts would help to standardize infusion device drug libraries, reduce the risk of prescribing and pump programming errors, and eliminate confusion when transferring critically ill neonates from one facility to another.
Recommendation:  ISMP and VON developed a list of standard drug concentrations for neonates ( Tools/NeonatalConcentrations) to be used as recommended default concentrations to cover at least 80% of the needs in neonatal patients. All NICUs are urged to incorporate these standard concentrations into their practice sites when possible. ISMP and VON also are urging vendors to commercially prepare medications in these standard concentrations.

vPreventing medication errors during codes (3)
Problem: Cardiac and/or respiratory resuscitation is a critical situation during which healthcare practitioners have little time for discussion and verification of the patient’s treatment plan, including medications. During these medical emergencies, every second counts and every errant action or inaction can result in patient harm or death. Observation-based simulations of codes have a documented medication error rate of up to 15%.
Recommendation:  Activate a rapid response team when warranted to help prevent full codes. Also consider the following: 1) Utilize separate adult and pediatric code carts, 2) Supply a neonatal emergency drug box/tray on code carts with neonatal-specific formulations in standard concentrations, 3) Provide drug reference sheets and IV titration dosing guides for all drugs (in the concentrations available) in the cart, including admixture information, dosing instructions, maximum dose limits, and infusion rates. Additional strategies can be found at: acutecare/articles/20110210.asp.

v Ensuring safety with alternatives used during electrolyte shortages  (5)
Problem: The national shortage of common electrolyte solutions in certain strengths and sizes has forced many hospitals to replace their standard injectable solutions with a different product.
Recommendation: Follow a verification process for purchasing alternative electrolyte products. Ensure that necessary changes are made in computer software (e.g., IV compounders and robots, automated dispensing cabinets, computer order entry systems, smart pumps, other affected technology).

 v Caution with concentrated sodium chloride NaCl 23.4% (Ameridose) minibags(4)
Problem: Due to a shortage of sodium chloride concentrate (23.4% and 14.6%) in vials, compounding pharmacies are supplying these products to some hospitals. One compounder provides the sodium chloride 23.4% solution in a minibag. Packaging the product in a minibag—as opposed to a vial—may lead to the mistaken belief that the product can be administered as is, despite labeling that it must be diluted for IV use.
Reccomendation: During the shortage, purchase the electrolyte in vials (available from some compounding pharmacies). If you elect to use a minibag, perform a failure mode and effects analysis (FMEA) and address potential risks before the product is obtained and placed into use. Consider implementing pharmacist double checks and segregating the storage of these products away from other minibag infusions.

vDosing error with new TAXOTERE (DOCEtaxel) concentration (6)
Problem: A patient on Taxotere received 100 mg/m2 instead of a reduced dose of 50 mg/m2 soon after an ambulatory cancer center pharmacy began using the new 20 mg/mL one-vial product instead of the previous 10 mg/mL two-vial preparation. Adding to the confusion caused by changing the Taxotere concentration, a generic one-vial DOCEtaxel product (Hospira) is now available in a 10 mg/mL concentration, the same concentration as the older two-vial Taxotere.
Recommendation:  Alert pharmacy staff and oncology nurses to the new 20 mg/mL Taxotere and 10 mg/mL generic DOCEtaxel (both one-vial products). Update computer databases and drug resources to ensure proper mixing. If your computer system allows order replication from past admissions, work with IT staff to intercept orders for medications with changed strengths. For details, visit: and

vB. Braun’s heparin and HESPAN (hetastarch) mix-up (4)
 We continue to receive reports of mix-ups between B. Braun’s heparin and Hespan. Both products have red and blue lettering, and share several letter characters in the same sequence—“H-E,” “P-A,” and “N.” With Baxter’s withdrawal of premixed heparin from the market, more hospitals will be purchasing both products from B. Braun.
Recommendation: Consider using one of the generic alternatives to Hespan, and refer to hetastarch products by the generic name. Use bar-coding technology to help prevent packaging or container mix-ups. B. Braun has agreed to work with ISMP on label improvements to reduce error potential.

vAdjust PRADAXA (dabigatran etexilate mesylate) dose for renal impairment(3)
A cardiologist prescribed Pradaxa for an outpatient with stage IV chronic kidney disease without adjustment for renal impairment. After a follow-up office visit during which tarry stools and a low hemoglobin and hematocrit were identified, the patient was admitted to a critical care unit with a massive gastrointestinal bleed. 
Recommendation: Encourage practitioners to pay as much attention to safe prescribing of Pradaxa as they would for warfarin. Ensure that your computer system(s) is/are updated with Pradaxa drug interactions and renal dosing recommendations.

vMixing multi-chamber bags of CLINIMIX (amino acid and dextrose) or CLINIMIX E (amino acid and dextrose with electrolytes) (5)
Nurses have failed to break the seal that separates two chambers of Clinimix products before administration, a key step for properly mixing the amino acids and dextrose (and electrolytes with Clinimix E) prior to administration to patients. In both cases, the amino acids and electrolytes infused without the dextrose. 
Recommendation:  Have pharmacy dispense the products after proper mixing and labeling. All TPN should be initiated when a pharmacist is on site to provide this service. If the product is available and still in its overwrap in patient care units, teach nurses how to activate this product (

Federal legislation by Sens. Amy Klobuchar (D, MN) and Robert Casey, Jr. (D, PA) to address drug shortages (3)
Hospitals are increasingly affected by ongoing drug shortages, which pose a hazard to patient safety. Currently, companies are only required to notify FDA of an impending shortage or decision to stop production if they are the sole provider of the drug and it’s a medically necessary product; even then, companies rarely report impending shortages.
Recommendation:  Federal legislation (S.296) was introduced to support FDA efforts to address drug shortages ( detail.cfm?id=330941&). The legislation would require manufacturers to notify FDA of drug shortages or a decision to stop producing a product. Contact your legislators, invite them to your hospital to see the drug shortage issue firsthand, and ask them to co-sponsor S. 296.

A patient verification process is needed everywhere, not just at the bedside (5)
 “Wrong patient” medication errors can occur for a variety of reasons at any phase of the medication use process. Prescribers have entered orders into the wrong patients’ records, or prescribed therapy based on misfiled lab results for another patient. Telephone orders have been mistranscribed onto the wrong patients’ records. Patient labels have been applied to the wrong patients’ order forms. Pharmacists have entered orders into the wrong patients’ profiles.
Recommendation:  All staff (not just nurses) should use two identifiers to identify/verify patients during all patient-associated tasks in the medication use process: when physicians prescribe medications; when pharmacy staff enter orders and dispense medications; when unit staff and nurses transcribe orders; when staff file test results; and when nurses administer medications. Design technology systems to limit access to an applicable set of patients, not all patients within the facility.

Potential mix-ups between hepatitis B immune globulin (Talecris) neonatal and adult syringes (5)
It is difficult to distinguish Talecris’ hepatitis B immune globulin packages of the 0.5 mL 110 unit syringes for neonatal use and the 1 mL 220 unit syringes for adult use. Both also list the dose using “IU” for international units. If the “Do not…” part of the “Do not give intravenously” warning is overlooked, IU could be misread as IV.
Recommendation:  Both syringes from this manufacturer should not be stocked. If you must stock both products from Talecris, be sure to circle the volume on the package to help users differentiate them.

Observation of peer behaviors teaches others about safety (4)
 A safety culture study found that the two strongest predictors of high-level patient safety behaviors for all healthcare workers were seeing peers engaged in the behaviors, and believing that the behaviors would result in positive safety outcomes. Medical residents demonstrated the lowest intent to engage in patient safety behaviors; nurses were six times more likely than medical residents to exhibit safe behaviors.
Recommendation:  The influence of credible, clinical leaders who believe in and model patient safety behaviors in the workplace is key; thus hospital leaders—including physician leaders—should encourage this type of mentorship and ensure that the actions of all professional staff send a clear positive message about the importance of engaging in key patient safety behaviors (e.g., consistent use of technology, critical thinking about drug therapy, adherence to practices that prevent errors).

Mix-up between tuberculin purified protein derivative (PPD) and inactivated polio vaccine (IPV) (6)
A medication error occurred when a public health nurse, intending to administer a tuberculin (PPD) skin test, mistakenly administered 0.1 mL of injectable inactivated polio vaccine (IPV). The polio vaccine had been placed accidentally in the PPD carton, and the PPD vial had been incorrectly placed in the polio vaccine carton.
Recommendation:  Require practitioners to document the vaccine in the vaccine log, including lot number of the drug vials, prior to administration. (Actual administration should be documented after administration.) Store PPD in its original carton since it is light sensitive. For products that aren’t light sensitive, discard cartons once the products are opened.

RAPAFLO (silodosin) and RAPAMUNE (sirolimus) mix-up  (1)
A recently admitted patient was ordered to continue taking his home medication Rapaflo 8 mg PO daily. The pharmacist misread the order as Rapamune 8 mg PO daily. Rapaflo was a nonformulary drug that was not in the computer system. Unfamiliar drug names are more likely to be misinterpreted as more familiar drug names. The wrong drug was administered for 5 days.
Recommendation: Consider adding this drug name pair to your list of look-alike product names, and building an alert in computer systems to warn about mix-ups. Prescribers can help prevent possible mix-ups by including the drug’s indication when ordering medications, regularly reviewing the patient’s medication list, and assuring staff understand the order at the time of prescribing.

Addressing noncompliance with “Do Not Use” abbreviations  (2)
Hospitals continue to be cited by The Joint Commission for not addressing medical orders with abbreviations on the organization’s “Do Not Use” list. This issue requires the medical staff and/or hospital leadership to step up to the plate and address repeated prescriber non-compliance and refusals to return calls associated with clarification of orders with unapproved abbreviations.
Recommendation: Enforcement of prohibited abbreviations requires more than asking pharmacists or nurses to alert prescribers to lapses in compliance. Approach this as a system-wide problem that requires peer-to-peer physician interaction along with full support from leadership. Additional recommendations to reduce the use of abbreviations can be found at:

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

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved