ISMP Quarterly Action Agenda: April - June 2002

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One of the most important ways to prevent medication errors is to proactively seek and use knowledge from other organizations that already have experienced similar problems. To promote such a process, administrative staff and an interdisciplinary committee at each practice site should review the following material to prompt discussion and stimulate action to reduce the risk of errors. The following selected items appeared in the ISMP Medication Safety Alert! between April - June 2002. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information as desired. Many product-related problems can be visualized in the ISMP Medication Safety Alert! section. The American Society of Health Care Risk Management (ASHRM) routinely provides the ISMP Quarterly Action Agenda to all its members. ACPE credit is available for pharmacists (see www.ismp.org for details).

I. Problematic nomenclature, labeling, and packaging of products

• AVINZA (morphine sulfate extended release) and INVANZ (ertapenem) confusion (8, 10)
  Problem: Confusion is possible between Avinza, a once-a-day capsule for 24-hour pain control, and Invanz, a new parenteral antibiotic from Merck. The name "Invanz" also has been mistaken as "IV Vanc."
  Recommendation: Always include dose and route of administration when communicating orders for Invanz. Do not use word stems such as "Vanc" for vancomycin, or statements such as "put the patient on Avinza" or "start Avinza," where dose and route are not specified.
• FEMARA (letrozole) and FEMHRT (ethinyl estradiol/norethindrone acetate) mix-up (7)
  Problem: An oncologist prescribed Femara for a postmenopausal woman with recurrent breast cancer, but the patient received the hormone replacement drug FEMHRT. These names look and sound similar and both are prescribed to women for conditions related to menopause. Recommendation: Prescriptions for Femara should include the strength to differentiate it from FEMHRT. Place reminders on drug containers and in computer systems. Warn patients about the risk of mix-ups.
• Generic drug name mix-ups (13)
  Problem: A physician confused valacyclovir (VALTREX) with valganciclovir (VALCYTE). The generic (and brand names) sound very much alike and are easily confused, and both have uses associated with cytomegalovirus. In another error, anakinra (KINERET), an interleukin 1 blocker, was prescribed but amikacin (AMIKIN) was dispensed.
  Recommendation: Use both brand and generic names when prescribing these medications.
• FORADIL (formoterol) and TORADOL (ketorolac) mix-up (12)
  Problem: A handwritten Foradil prescription for an asthma patient was mistaken for the nonsteroidal anti-inflammatory drug Toradol. The names also may sound alike when communicating orders orally.
  Recommendation: For this name pair, as well as others cited above, review the prevention suggestions outlined in "What's in a name? Ways to prevent dispensing errors linked to name confusion," which appeared in our June 12, 2002 issue.
• Unsafe labeling of respiratory therapy medications and certain injectables in plastic vials (10)
  Problem: Some respiratory therapy medications and certain injectable products are packaged in low-density polyethylene (LDPE) vials that look nearly identical. Drug names, strengths, lot numbers and expiration dates are embossed on the containers in transparent, raised letters, which are almost impossible to read. FDA will no longer permit paper labels or colored inks applied directly to LDPE containers because the potential for adverse effects of volatiles in label glue is not well defined.
  Recommendation: When packaging alternatives exist (especially for injectables), pharmacy and group purchasing organizations should avoid LDPE ampuls with embossed labels. Do not store respiratory medications together in a single bin. Affix auxiliary labels before dispensing. At least one manufacturer (Nephron) provides medications as unit doses with labeled outer packaging. Ensure respiratory medications are ordered through the pharmacy.
• Etomidate and neostigmine mix-up (12)
  Problem: Two patients undergoing electro-convulsive therapy felt discomfort during their procedures when they received neostigmine, an anesthesia reversal agent, instead of the intended etomidate, a general anesthetic. Etomidate vials (2 mg/mL) and neostigmine vials (1:1,000) are packaged by Bedford Laboratories in the same size (10 mL vials) and have black and gray lettering and numbers on the label.
  Recommendation: If you carry these two products, purchase one from a different manufacturer.
• ARIXTRA (fondaparinux) confused with Anti-Xa lab test (11)
  Problem: There were two near misses involving pharmacists who confused orders for the lab test, anti-factor Xa (expressed as "Anti-Xa"), with the once-a-day, low molecular weight heparin (LMWH) product, Arixtra.
  Recommendation: Order the lab test as "anti-factor Xa." Orders for Arixtra always should specify the drug, dose, route and frequency.
• Removing plastic IV containers overwraps allows evaporation (11)
  Problem: If premixed IV bags are removed from their protective overwrap, the drug's concentration increases over time as the fluid volume within the container decreases due to evaporation of fluid through the bag wall.
  Recommendation: Don't remove premixed IV bags from their protective overwraps far in advance of dispensing. Once removed, consider environmental factors (e.g., humidity, temperature) and the material used by the manufacturer to ensure proper storage. For less frequently used products, place a label with the expiration date on part of the bag that does not come into contact with the solution.
• Dual-chamber IV bags (13)
  Problem: A dual-chambered IV bag (lower chamber with amino acids, upper chamber 50% dextrose) used for parenteral nutrition (PN) solution was not mixed prior to dispensing. The patient received a concentrated solution, including electrolytes and insulin.
  Recommendation: Consider adding multivitamins to each PN bag to assure inactivated bags are readily recognized (split the daily dose so that the yellow vitamins are visible in each bag). Incorporate independent double checks of work and a checklist to assure that the full contents of the bag have been mixed. Nurses also should check bags to assure proper mixing.
  

  II. Dangerous abbreviations, confusing dose designations, and unsafe ways of communicating orders

• Computer screen abbreviations (8)
  Problem: Software-related problems can lead to omitted characters or the display of wrong characters. For example, the Greek letter character "mu" for "micro" does not always translate well or it might not be seen at all in certain word processing programs.
  Recommendation: When expressing drug doses in word processing or other programs, avoid using symbology (including apothecary symbols). Also avoid the handwritten "mu" character because it can look like an "m," which could be misunderstood as milligram. The safest abbreviation to use for microgram is mcg.

• Hazardous abbreviations (10)
  Problem: The abbreviation "AD" used for right ear (aura dexter) has been mistaken for a variety of other meanings: OD (right eye - oculus dexter); QD (once daily); PO (by mouth); and "as directed" on prescriptions. One patient received eardrops in the eye. Using AS for left ear or AU for each ear also might cause problems.
  Recommendation: These abbreviations should be avoided.

• Erroneous daily dosing of medications for weekly administration (10)
  Problem: Fatalities have been reported in patients who have been prescribed a once-a-week dose of methotrexate (e.g., for rheumatoid arthritis, asthma, psoriasis, inflammatory bowel disease, myasthenia gravis, inflammatory myositis). Relatively few medications are dosed in this manner and the drug has been accidentally prescribed or dispensed daily instead of weekly.
  Recommendation: Build alerts in electronic prescribing and pharmacy systems and configure them to avoid defaulting to a daily dosing schedule. Verify proper dosing, confirm the correct dosing schedule on medication administration records and prescription labels, and educate staff and patients. Prescribe and dispense unit-of-use dose packs (e.g., RHEUMATREX by Lederle), which helps to reinforce the weekly dosing schedule.
  

  III. Other discussion items
  
• Topical lidocaine toxicity (10)
  Lidocaine is extensively absorbed, up to 35%, after topical administration to mucous membranes. This can lead to toxic plasma levels if large amounts are used, such as during bronchoscopy. Extra care is needed in infants, the elderly, and those with liver or cardiac impairment. Protocols should specify a maximum dosage. Make sure new house staff are aware that topical lidocaine is absorbed from mucous membranes.
• Pediatric medication error prevention guidelines (13)
  ISMP and the Pediatric Pharmacy Advocacy Group (PPAG) have published the first comprehensive consolidation of recommendations to reduce the risk of medication errors in the pediatric population (also endorsed by The Society of Pediatric Nurses) in The Journal of Pediatric Pharmacology and Therapeutics. The guidelines also are available on the ISMP website.
• Gathering creative solutions to prevent errors (12)
  A community hospital placed suggestion boxes and forms by the elevators to prompt information about safety issues and concerns. The hospital invites patients, visitors, and staff to provide their perspective and creative solutions for improvements. This may be a valuable, untapped resource that can help lead to improvements in safety and patient care.