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ISMP Medication Safety Alert

ISMP Quarterly Action Agenda: April-June 2004


From the July 1, 2004 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 agenda items have been prepared for your administrative staff and an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. These agenda topics appeared in the ISMP Medication Safety Alert! between April and June 2004. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number (in parentheses) to locate additional information as desired. Many product-related problems may also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses.

I. Issues Related to Patient Information

  • Tracking KAYEXALATE (sodium polystyrene sulfonate) orders (10)) Problem: A patient with a serum potassium of 6.2 mEq/L had an ongoing order for Kayexalate 15 grams four times daily. The medication continued without lab monitoring, and the patient's potassium level dropped to 2.2 mEq/L.

    Recommendation: Establish an automatic consultation to pharmacy for standing Kayexalate orders, and allow the pharmacist to order daily serum potassium levels, as needed, and discontinue Kayexalate if the patient's potassium level falls below a defined threshold.

  • "Wrong patient" errors occur during all phases of medication use (11)

    Problem: Order entry errors have happened in the pharmacy when the patients' names/identification numbers are poorly visible on order forms. Misidentified cardiac monitors have led to administration of antiarrhythmic medications to the wrong patient. One infant received medication intended for another infant; both medication administration records (MARs) were lying side-by-side.

    Recommendation: Although the Joint Commission requires two forms of identification before drug administration, perhaps this rule should be expanded to include all phases of medication use. To facilitate this, establish a reliable way to communicate two forms of patient identification to all clinical and support staff involved in medication use.

  • The high cost of medications (10)

    Problem: A recent survey indicated that paying for prescription medications was a problem for one out of every three families. This causes patients to delay filling their prescriptions, skip doses, or obtain medications at a reduced rate from foreign pharmacies where FDA oversight is lacking.

    Recommendation: Assess the financial capabilities of patients to obtain medications and consult with a pharmacist to suggest less costly items. Direct patients to government or manufacturer assistance programs for help with purchasing their medications. Alert patients to the risk of obtaining medications from foreign pharmacies.

II. Issues Related to Drug Information
  • Adding insulin to infant TPN (11)

    Problem: An order for 1 unit of regular insulin in a 327 mL bag of TPN for a 1.3 kg infant was prepared using the wrong insulin concentration (100 unit/mL instead of 10 unit/mL), resulting in a 10-fold overdose. Luckily, the error was caught 2 hours after infusion, but not before the baby's blood sugar plummeted to 3 mg per dL. Contributing factors included an inexperienced pharmacy technician and a failed double check by the pharmacist.

    Recommendation: Many feel it is best practice to treat hyperglycemia in patients on TPN with a separate insulin infusion, which can be adjusted independently to control the patient's blood glucose level. When mixing neonatal insulin solutions (in the pharmacy), use a standard dilution of insulin, clearly labeled as "NICU ONLY." Also, segregate materials used to prepare neonatal TPNs from adult products.

  • Find all hidden patches (10)

    Problem: An obese woman was admitted to the hospital wearing a 75 mcg/hour fentanyl patch, which was hidden in a skin fold. She failed to mention the patch, and another one was prescribed and applied. She was found unresponsive the next day.

    Recommendation: Educate patients to question the application of a new patch if the current patch has not been removed. It may be advisable to perform a complete skin assessment before the application of opiate-containing patches.

  • Burns on MRI patients wearing transdermal patches (7)

    Problem: Patients have experienced burns when undergoing an MRI while wearing a medication patch. Some patches contain an aluminized backing, which becomes heated when exposed to radiofrequency pulses.

    Recommendation: Before an MRI, ask the patient about the use of any medication patches. Unless the facility can verify that the patch does not contain metal, counsel the patient to remove it temporarily during the procedure.

III. Issues Related to Drug Labeling, Packaging, and Nomenclature

  • Fatal potassium errors with dialysis solutions (7)

    Problem: Removing concentrated potassium chloride from patient care units is not enough to prevent fatal errors. This medication is still available in pharmacies, where potentially fatal preparation errors have occurred. For example, two patients died because of a mix-up between sodium chloride and potassium chloride solutions when preparing dialysis solutions. Similar appearance of the shipping cartons, close proximity of the boxes, and a failed check system contributed to the error.

    Recommendation: Perform a failure mode and effects analysis on the storage of all concentrated electrolytes in the pharmacy, paying attention to the look-alike potential of product containers. Store concentrated electrolytes in segregated areas. Do not compound electrolyte solutions that are commercially available. Establish an independent check of all electrolyte products upon delivery and preparation.

  • BRETHINE (terbutaline) and METHERGINE (methylergonovine) (8)

    Problem:
    A physician prescribed Brethine for a woman experiencing preterm contractions. The nurse accidentally obtained an ampul of Methergine from floor stock, which was packaged in a brown tub just like Brethine. She administered Methergine, which led to an emergency C-Section to deliver the baby.

    Recommendation: Alert all staff to the potential for errors with these products. Store these products separately (refrigerate Methergine ampuls) and apply label reminders to the brown tubs and/or ampuls to prevent mix-ups.

  • NEUMEGA (oprelvekin) and NEULASTA (pegfilgrastim) (8)

    Problem: A dispensing error led to administration of Neulasta to a patient instead of Neumega. Similar names, overlapping dosage ranges, and close proximity of the vials in the refrigerator contributed to the error.

    Recommendation: To avoid mix-ups, segregate the storage of these two products in the refrigerator. Consider placing each syringe of Neulasta in a separate plastic baggie with a warning sticker. Also include cautionary warnings in the pharmacy computer system.

  • HYALGAN and HEALON (9)

    Problem: During a cataract procedure, a nurse gave a surgeon Hyalgan (used for arthritic joints) instead of Healon. Although both products contain sodium hyaluronate in the same concentration, they are formulated differently and cannot be used interchangeably. During administration, the surgeon noticed the difference in viscosity and was able to remove what had just been injected.

    Recommendation: If you carry both products, add auxiliary labels to the cartons to highlight the different indications.

  • TEMODAR (temozolomide) labeling problem (9)

    Problem: A physician prescribed Temodar 60 mg daily for a patient with a brain tumor. When filling the prescription, a pharmacist misunderstood the number of capsules (20) printed on the bottle as the strength, and filled the prescription using 100 mg capsules, not the intended 20 mg capsules (three for each dose).

    Recommendation: Affix auxiliary labels to the products and highlight the strength with a marker to draw attention to it.

  • SINGULAIR (montelukast) packaging similarity (12)

    Problem: Varying strengths of Singulair have been mixed up because they are packaged in unit doses using a common light blue and white color scheme, with each strength listed inside similar-looking geometric shapes.

    Recommendation: Store the various strengths separately. Use auxiliary labels on shelves to help staff find the different strengths. When possible, limit the variety of strengths stocked for this product.

  • Ambiguous concentration expression with TAXOTERE (docetaxel) (12)

    Problem: A recent FDA-mandated label change has resulted in potential confusion regarding the concentration of Taxotere. The expressions on the outside cartons now read "80 mg/2 mL" or "20 mg/0.5 mL," which represent the initial concentrations before dilution. Pharmacy staff could misunderstand this as the final concentration used to prepare the patient-specific dose after initial dilution (10 mg per mL).

    Recommendation: Build an alert into the pharmacy computer so that information about the concentration appears as a warning on admixture labels used to guide the preparation of this product.

IV. Drug distribution, pumps, and computers

  • Improvised delivery of GOLYTELY (PEG-3350 and electrolytes) (8)

    Problem: An ED physician prescribed GoLYTELY via a nasogastric tube for a child who had ingested multiple mercaptopurine tablets. The solution was administered by jury-rigging an IV set to fit the nasogastric tube, but the connection was accidentally made with the IV line. The child received 391 mL IV, but suffered no permanent harm.

    Recommendation: Hold focus groups to learn why nurses might need to improvise in order to administer enteral feedings (or other situations where an unintended tubing/delivery device might be used for drug delivery). The reasons are usually rooted in system problems for which safer solutions can be found.

  • BICILLIN (penicillin G benzathine) syringe enhancements (9)

    Problem: A physician accidentally administered Bicillin intra-arterially while attempting an intramuscular injection, causing tissue loss. Intravascular administration (IV) has also been associated with cardiorespiratory arrest due to pulmonary embolism of insoluble material.

    Recommendation: Prefilled Bicillin syringes and Tubexes now facilitate visualization of aspirated blood when blood vessels are inadvertently entered during administration. Also, consider wrapping an auxiliary label around the needle covers of Bicillin products, stating "For IM Use Only" as an added precaution. Alerts that slightly hinder use are more likely to be noticed.

  • Tubing misconnection causes child's death (12)

    Problem: A child's oxygen tubing (AIRLIFE by Allegiance Healthcare Corporation) became disconnected from his nebulizer and was accidentally reattached to his IV tubing Y-site (CLEARLINK by Baxter). The connection was broken in seconds, but not before an air embolism caused the child's death.

    Recommendation: Review the medical equipment in your facility to identify the potential for dangerous misconnections to IV tubing. Educate staff about this hazard, and require tracing of tubing connections from patient to point of origin for verification. Identify all staff who may be asked to connect or disconnect various tubings attached to patients to make sure this activity falls within a safe and acceptable scope of practice for each practitioner type.


The ISMP Quarterly Action Agenda is now approved for Continuing Pharmaceutical Education by the Pennsylvania Society of Health-System Pharmacists. Each Action Agenda will be approved for one contact hour of continuing education (0.1 CEU).
Learning objectives and instructions for applying for CE are available at the PSHP CE Center.

The Pennsylvania Society of Health-System Pharmacists is approved by the American Council of Pharmaceutical Education as a provider of continuing education and complies with the criteria for quality continuing pharmaceutical education programming.

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