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
I. Issues Related to Patient
II. Issues Related to Drug Information
- Tracking KAYEXALATE (sodium polystyrene sulfonate)
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
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
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.
- 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
- Burns on MRI patients wearing transdermal patches
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)
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
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)
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
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
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)
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
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
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.
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of Health-System Pharmacists is approved by the American
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