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ISMP Medication Safety Alert
ISMP Action Agenda: January - March, 1999

From the April 21, 1999 issue

One of the most important methods for preventing adverse drug events is for organizations to seek and use knowledge from other organizations that have already experienced problems. Since ISMP believes that it will make a significant impact on error prevention efforts, administrative staff and an interdisciplinary committee at each practice site should review the following agenda to prompt discussion, and then take the necessary action to prevent these adverse drug events in your facility. The following selected items appeared in the ISMP Medication Safety Alert! between January and March, 1999. Each item is followed by a description of the problem, recommendations for safe medication practices and the issue number (in parenthesis) to locate additional information. The American Society of Health Care Risk Management (ASHRM) provides the quarterly ISMP Action Agenda to its members.

I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • CELEBREX (celecoxib), CEREBYX (fosphenytoin), CELEXA (citalopram) (1), (3), (4)
    Problem: Celebrex, Searle’s new COX2 inhibitor, has been confused frequently with Cerebyx and Celexa.
    Recommendation: Encourage physicians to include the drug’s indication when prescribing these products. Add an alert to the pharmacy computer to remind pharmacists to verify the patient’s diagnosis. Limit verbal orders to emergency situations and spell the name back to prescribers along with the practitioner’s understanding of the drug’s indication.
  • Baxter Pharmaceutical Products Division products (6)
    Problem: Labeling and packaging of various Baxter critical care drugs, such as pancuronium bromide, phenylephrine 1%, metoclopramide and atropine, are strikingly similar and can be confused if the products are inadvertently stored together.
    Recommendation: Baxter has been asked by ISMP to redesign the packaging and labeling of these products. FDA has been informed. For now, purchase high alert drugs such as pancuronium from a different supplier to reduce similarity.
  • HERCEPTIN (trastuzumab) and NEUMEGA (oprelvekin) (5)
    Problem: Herceptin and Neumega are packaged with diluent in volumes larger than needed for proper dilution. While package inserts direct staff to use the correct amount of diluent, dosing errors are occurring when full diluent vials are used.
    Recommendation: Add visible reminders about proper reconstitution to each package placed in inventory. ISMP has asked
    manufacturers to provide diluent in exact volumes or, for now, to place visible dilution directions on the diluent vial.
II. Misinterpretation of abbreviations and symbols
  • EPO used as an abbreviation for evening primrose oil (3)
    Problem: A pharmacist determined that a patient with an order to “Take own supply of EPO” was not anemic. After interviewing the patient, he identified that the abbreviation, EPO, was intended for evening primrose oil, and not as a synonym for epoetin.
    Recommendation: Avoid using drug name abbreviations and assure that pharmacists have easy access to patients and medical records, including laboratory values, to help verify accurate interpretation of drug orders.
  • TPN used as an acronym for a chemotherapy regimen (4)
    Problem: “TPN,” readily recognized as “total parenteral nutrition,” is now being used as a chemotherapy acronym for the drug regimen which combines TAXOL (paclitaxel), PLATINOL (cisplatin) and NAVELBINE (vinorelbine).
    Recommendation: Avoid this dangerous acronym. Establish and enforce policies that prohibit use of dangerous abbreviations/acronyms in written and verbal orders, preprinted orders and protocols, computer drug profiles, MARs and drug labels.
  • 4-MP, an abbreviation for ANTIZOL (fomepizole) misinterpreted as 4-mercaptopurine (6)
    Problem: Although a synonym for mercaptopurine is 6-MP, a verbal recommendation from a poison-control specialist for 750 mg of 4-MP (4-methylpyrizole, the chemical name for fomepizole) was incorrectly transcribed as 4-mercaptopurine.
    Recommendation: Do not use chemical names of drugs. Use only the USAN generic name and applicable brand names.
  • ampersand (&) misinterpreted as the number 2 (2)
    Problem: A pharmacist misinterpreted an ampersand as a “2” in a written order for “Insulin N 70/30 10U qAM &8U qPM.” Insulin directions advised administration of “10 units in the morning and 28 (rather than 8) units in the evening.”
    Recommendation: Encourage prescribers to write the word “and” (also “units”) to avoid confusion or to write complete and separate orders for morning and evening insulin doses. To detect errors, counsel patients when dispensing drugs.
  • “hs” misinterpreted as a daily bedtime dose (6)
    Problem: Confusion over interpretation of “hs” as a one-time dose at bedtime or a daily bedtime dose led to a patient’s death when he received lomustine for nine consecutive days at “hs” instead of a single “hs” dose as intended.
    Recommendation: Encourage prescribers to specify “hs nightly” if the drug should be administered each night; “hs nightly prn for (name of condition)” if the drug should be administered each night as needed; and “hs x 1 dose on (date)” if the drug should be administered as a single dose at bedtime. Clarify any unclear orders with prescribers.
III. Miscellaneous
  • Dangerous chemicals left at the patient’s bedside (1)
    Problem: A respiratory therapist accidentally diluted albuterol with 5% acetic acid, which was left in a container at the patient’s bedside to clean his tracheotomy tube. The 10-month old child’s asthma worsened shortly after treatment.
    Recommendation: Assure that potentially hazardous chemicals are properly stored away from patients and clearly labeled to indicate toxicity. Pharmacists should regularly visit patient care areas to monitor compliance.
  • Oral medications administered IV (1)
    Problem: TYLENOL LIQUID (acetaminophen) and VERSED SYRUP (midazolam hydrochloride) were combined in a parenteral syringe and inadvertently administered IV to an 11-year old child.
    Recommendation: Require staff to administer oral solutions from medication cups or specially designed oral syringes that will not connect to IV tubing ports. If possible, use small-bore feeding tubes that are compatible with oral syringes.
  • Oral syringe tip caps may pose a potential choking hazard (5)
    Problem: The tip caps on some oral syringes may explosively dislodge into a patient’s mouth if staff or parents fail to remove them before attempting to administer oral solutions. Tip caps also pose a choking hazard if they are left within reach of children.
    Recommendation: Instruct staff and parents to properly remove and dispose oral syringe tip caps before administering drugs to prevent accidental ingestion or asphyxiation. Consider purchasing oral syringes that do not allow accidental dislodgment of the tip caps (e.g. Exacta-Med Oral Dispenser by Baxa).
  • Lack of unit dose system in NICU (4) (A similar error was reported in our Sept 9, 1998 issue)
    Problem: A neonate sustained cardiac damage after receiving 11 mL (25 mg/mL) of aminophylline instead of 11 mg. The drug was removed from an automated dispensing cabinet and given without being double-checked.
    Recommendation: Have pharmacy prepare and dispense all non-emergency parenteral drugs in unit-of-use doses. Establish a double-check system before administering high alert drugs, especially when they are obtained from dispensing cabinets.
  • Changes in the expected appearance of a drug not investigated fully (4)
    Problem: When pharmacists in one case dispensed mitomycin instead of mitoxantrone and in another case prepared an overly concentrated solution of intrathecal methotrexate, nurses questioned the unexpected appearance of the solution’s color, but the changes were attributed to differences in manufacturers’ products and not fully investigated.
    Recommendation: Any reported change in the expected color or appearance of a drug should be considered a “red flag” and thoroughly investigated prior to administration.
IV. Discussion Items
  • Non-punitive approach to error reduction (1), (2)
    The Massachusetts nursing board is punishing 18 nurses involved in the 1994 fatal chemotherapy error at the Dana Farber Cancer Institute. A punitive approach to errors inhibits open discussion about errors, creates a defensive environment and hinders careful consideration of the system-based causes of errors. A non-punitive approach to errors does not diminish individual or organizational responsibility. It directs it in a productive and realistic manner by encouraging error detection and reporting, analysis of root causes and implementation of system-based prevention strategies.
  • Over-reliance on pharmacy computer systems may place patients at great risk (3)
    An ISMP computer field test identified that pharmacy computer systems need serious improvement (only 4/307 systems tested detected all unsafe orders presented in the field test). Many systems were unable to link drug information with critical patient information, such as laboratory results, and detect potentially lethal drug orders, including drug doses that exceed safe limits, drug ingredient duplication and oral solutions ordered IV. Do not rely on pharmacy computer systems alone to detect unsafe orders. Build alerts in computer systems for error prone situations, such as those reported in the ISMP Medication Safety Alert!, and regularly load vendor drug information updates into the system in a timely manner.
  • Phrases that should be considered red flags, not evidence (4)
    Many times reports of lethal errors involve situations where orders were questioned but not changed. This often results when practitioners are intimidated into carrying out orders they question or when they are easily convinced that an order is safe. Prescribers sometimes use phrases such as “we always give it that way,” or “this is a special case” to convince practitioners to carry out orders. These should be considered “red flags” that require more reliable answers or evidence in hand.
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