ISMP Quarterly Action
Agenda - April-June 2003
From the August 7, 2003 issue
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 and June
2003. 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 of our web site. ACPE credit is available for pharmacists
I. Drug Information
.II. Communication of Medication Orders
- How fast is too fast for IV push medications (10)
Problem: A study in the UK suggested that the
most common error with IV medications is too rapid administration.
Recommendation: Provide maximum administration
rates for medications that have a high risk of adverse
effects when given too rapidly. Place these on pharmacy
labels, computer screens, MARs, in PDAs and in chart form.
An informative chart is being prepared for future publication
in Hospital Pharmacy.
Oral vancomycin does not treat systemic infections
Problem: We have received several reports of switching
patients with systemic infections from IV to oral vancomycin
at discharge. However, the oral form of vancomycin is
not absorbed systemically.
Recommendation: Computer screens and MARs should
alert professional staff that oral vancomycin is not absorbed
Dosing error with dextran (INFED, DEXFERRUM) (13)
Problem: The Washington Manual of Medical Therapeutics,
30th edition, implies that the patient's actual body weight,
not the lean body weight, should be used to calculate
the dose. This led to an overdose for an obese patient.
Recommendation: Design and implement a dosing protocol
for this medication and have a pharmacist verify all dose
calculations based on the patient's lean body weight before
dispensing the product.
Don't confuse lipid-based and conventional amphotericin
Problem: Cases of confusion between lipid-based
and conventional amphotericin B continue to be reported.
In the latest report of confusion, a patient received
the conventional product at a dose prescribed for the
lipid-based product, AMBISOME (amphotericin B liposomal).
Recommendation: Avoid storing conventional and
lipid-based products in close proximity. Prescribers should
refer to lipid-based products by their brand names. Place
appropriate warnings about the potential for confusion
in the pharmacy computer system. Require an independent
double-check if multiple vials of amphotericin B are needed
Converting oral hydromorphone to the IV route (10)
Problem: A physician converted an oral hydromorphone
dose of 2-4 mg every 4 hours to the IV route at the same
dose and frequency without recognizing that the proper
oral to IV conversion ranges from 3:1 to 5:1. The patient
experienced respiratory depression and required naloxone.
Recommendation: Provide staff education about opiate
dosing and update annually. Post oral to IV conversion
charts for opiates on patient care units. Have pharmacists
review all medication orders prior to administration.
Digoxin dose limits in the computer (10)
Problem: After adjusting the dose of digoxin for
a patient with renal insufficiency, a pharmacist entered
"0.63 mg" every 48 hours instead of "0.063
mg" and the patient received a ten-fold overdose
as a result.
Recommendation: Ensure that dose limits for digoxin
are set in the pharmacy computer. Also, consider expressing
digoxin doses in mcg.
III. Drug Labeling, Packaging, and Nomenclature
- HIPAA and listing an indication on prescriptions
Problem: There's a common misperception that listing
a medication's purpose on a prescription would violate
the HIPAA Privacy Rule.
Recommendation: According to the Department of
Health and Human Services, supplying this very important
information on the prescription does not violate the rule.
Although this is "Protected Health Information,"
it is not a violation to communicate it to another health
provider for treating the patient.
LANTUS (insulin glargine [rDNA origin]) and LENTE
(insulin zinc suspension) (10)
Problem: In the past, it was easier to avoid confusion
between Lantus and other insulin, such as Lente, because
of its unique bedtime administration. Now FDA has approved
a flexible daily dosing schedule, making it more difficult
to differentiate Lantus from Lente, especially if orders
Recommendation: Alert staff to the more flexible
dosing regimen. Also, educate patients and staff not to
mix Lantus with other insulins.
The dilemma between evidence-based and obvious
patient safety strategies (7)
Problem: Some practitioners have asked if evidence
exists to support the Joint Commission's National Patient
Safety Goal related to prohibition of abbreviations and
dose expressions that have led to medication errors.
Recommendation: Scientific research does not exist
to prove the effectiveness of this error reduction strategy,
but evidence for its adoption is nonetheless obvious.
Similar to how advances were made in aviation and nuclear
power safety, patient safety requires the adoption of
strategies that make sense and represent the obvious right
thing to do.
Drug protocols require groundwork (9)
Problem: Problems arose after a physician obtained
an insulin infusion protocol from another hospital and
sought quick approval for its use. The new protocol called
for dose adjustments every 2 hours, which resulted in
labile blood sugars. It was later discovered that the
original protocol was intended for patients who were receiving
tube feedings or TPN.
Recommendation: Allow adequate time to properly
review a new protocol before its adoption. Perform a failure
mode and effects analysis to determine vulnerable areas
and develop measures to gauge its effectiveness on a small
group of patients before spreading its use to all applicable
TNKase (tenecteplase) and ACTIVASE (alteplase)
mix ups (11)
Problem: Practitioners have confused Activase,
which is commonly referred to as t-PA, with TNKase, which
is sometimes called TNK or TNK-t-PA. Use of these abbreviations
led to three overdoses. In each case, TNKase was given
to a stroke patient at a dose appropriate for Activase,
the intended drug.
Recommendation: Avoid using abbreviations for these
thrombolytics. Minimize the variety of thrombolytics on
the formulary and standardize their use. Require an independent
double-check before use if these drugs are not dispensed
from the pharmacy (where they should also be double-checked).
IV. Drug storage, patient monitoring, and medical devices
- Fatal reports of intrathecal vincristine continue
Problem: Recently, the New Jersey media reported
two fatalities involving intrathecal administration of
vincristine instead of the prescribed medications, cytarabine
in one case, and methotrexate in the other.
Recommendation: Consider dispensing vincristine
in an IV bag with proper warning labels and an attached
IV administration set to differentiate it from intrathecal
syringes. Administer intrathecal medications in a specified
location and have pharmacy deliver them right before use.
Never deliver intrathecal medications with IV medications.
Require at least two health professionals to independently
verify the drug and dose before administration.
Ephedrine injection confused with epinephrine (8)
Problem: Similar names, indications and appearances
have led to mix-ups between epinephrine and ephedrine
ampuls, resulting in serious adverse outcomes for two
Recommendation: Differentiate these names on all
communication media, including pharmacy and nursing unit
storage bin labels, computer screens and MARs, using tall-man
lettering (EPINEPHrine, ePHEDdrine). When possible, use
prefilled syringes. If using automated dispensing cabinets,
screens should caution users about this potential problem.
Have pharmacy prepare all infusions and bolus doses of
METHERGINE (methylergonovine maleate) injection
and BRETHINE (terbutaline sulfate) injection (8)
Problem: These medications are packaged in amber
clear plastic unitdose blisters that make the products
look nearly identical and make reading the label difficult.
Several mix-ups have been reported.
Recommendation: FDA and the manufacturers are aware
of the problem, but changes have not occurred despite
numerous practitioner complaints spanning 3 years. We'll
continue to push for packaging changes but until that
occurs, if you must use these drugs, alert staff to the
problem, store these products separately, and apply label
reminders to caution against confusion.
Tetanus-diphtheria toxoid and tuberculin purified
protein derivative (9)
Problem: Groups of patients were given Td toxoid
intradermally instead of PPD, resulting in false positive
PPD readings and unnecessary administration of isoniazid.
Similar names and packaging may have contributed to the
Recommendation: Purchase these products from different
manufacturers when possible. Also, remove Td from unit
stock if feasible.
- Outbreak of infections linked to multiple-dose lidocaine
Problem: A recent outbreak of Staphylococcus aureus
infections has been associated with multiple-dose vials
of lidocaine used during injections into joints. Investigators
also found that refrigeration of the lidocaine vials after
initial use was a contributing factor (refrigeration actually
prolongs survival of any bacterial contaminants).
Recommendation: Use prefilled lidocaine syringes
or single-dose vials in areas outside the OR. If multiple-dose
vials are used, do not refrigerate them.
Pre-procedutre sedation by parents (10)
Problem: A pharmacist misinterpreted a prescription
for chloral hydrate liquid, "30 minutes before a
child's office visit" as "30 cc before office
visit." Subsequently, the mother of a 17-month-old
gave an overdose to the child just before leaving for
the physician's office. The child became comatose.
Recommendation: Never administer pre-procedure
sedation to a child at home. Skilled medical personnel
and resuscitation equipment should always be present before
sedation, and patients must be closely monitored.
Blood pressure monitor tubing may connect to IV
Problem: The tubing leading from blood pressure
monitors to certain disposable blood pressure cuffs may
have a male Luer connection. If so, there is a serious
risk that it may connect to a needleless Y site connection
integrated with certain IV administration sets. If such
a connection is made, the patient is at risk of air embolism
once the monitor attempts BP cuff inflation. Several fatal
cases have occurred.
Recommendation: Ensure that disposable blood pressure
cuffs do not have female Luer connectors. Place blood
pressure monitors on a different arm than IV catheters,
and remove IV catheters as soon as they are no longer
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