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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - April - June 2006

From the July 27, 2006 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 2006. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Many product-related problems can also be viewed in the ISMP Medication Safety Alert! section of our website.

The Action Agenda is also available for download ( in a Word format that allows expansion of the boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Continuing education credit is available for pharmacists and nurses.

Carpuject mix-ups (13)
Problem: Despite modifications in the packaging, mix-ups between various Carpuject products from Hospira continue to occur. The risk of error is heightened if only observing the tops or bottoms of the tubes when selecting, counting, or replacing Carpuject syringes.
Recommendation: Identify look-alike Carpuject syringes and store them separately in pharmacies and nursing units. Apply auxiliary labels to outer cartons and syringe cartridges. Leave the carton flaps intact so the name and strength of the drug is visible when supplies are removed from cartons. Consider double checking selected drugs or use single-dose vials for some products available in Carpujects (although the risk of an unlabeled syringe would be increased).

Scan/fax original order document(s) to pharmacy (8)
Problem: Orders received via document-imaging technology are often poorly legible if the "no-carbon required" (NCR) copy is scanned, rather than the original order.
Recommendation: Original order forms should always be scanned/faxed to the pharmacy, and NCR copies should be eliminated if no longer needed. Processes should be established to fax/scan and return one patient's orders to the chart at a time, and to indicate which order(s) have been sent to the pharmacy (e.g., stamp "faxed" or "scanned" near the orders).

Joint Commission no longer allows after-hours access to the pharmacy (10)
Problem: Patients are at risk for errors when non-pharmacists have access to a pharmacy after hours. Joint Commission standards now disallow access to any part of the pharmacy by non-pharmacist personnel after hours, even if permitted by law and regulation.
Recommendation: Hospitals without 24-hour pharmacy services should create a night formulary, store minimal amounts of these medications in a secured area outside the pharmacy, and provide on-call pharmacy services during off hours. Pharmacy staff should reconcile all drugs removed from the night supply via comparison against the physician's orders each morning.

Tablet splitting (10)
Problem: Tablet splitting has become more commonplace lately, especially since some health insurers have heavily promoted it. However, the practice increases the risk of dosing errors, clearly suggesting it is not the safest option if the patient's dose is available commercially.
Recommendation: Providers should make every effort to use whole oral tablets as available commercially. If tablet splitting is necessary, verify suitability of the drug, ensure that the patient has the required skills, educate the patient, and recommend using a tablet splitter.

“Never events” such as IV vincristine administered intrathecally (10)
Problem: Disturbing accounts of fatalities from accidentally administering IV vincristine by the intrathecal route are examples of a preventable "never events" that may have been side-lined as a priority because of its infrequency, despite relatively easy error-prevention strategies.
Recommendation: Take action to reduce the risk of "never events," even if their occurrence seems remote. For example, dilute vincristine in a 50 mL minibag (dilution in 20-50 mL for children) and administer it over 5-10 minutes, to reduce the risk of confusing vincristine as a medication in a syringe intended for intrathecal administration.

Rapid response team (RRT) activation by patients (11)
Clinical staff have sometimes minimized or ignored patients' and families' concerns about safety, which turned out to be warranted. Lack of a timely response to patient concerns has sometimes resulted in serious injuries, including fatalities.
Recommendation: Make patients an equal partner in their care and safety by allowing them (and families) to call for a RRT to address unresolved safety concerns. Called "condition H" in a hospital that helped shape this innovative process, the results after a year of implementation have been extremely positive.

TROPHAMINE (10% amino acid solution) and tromethamine (THAM) (7)
A pharmacist reported a near mix-up between Trophamine and tromethamine. Both drugs are packaged in 500 mL glass bottles and stored next to each other in this hospital.
Recommendation: To reduce the risk of mix-ups, use generic names when storing these products and when listing them on computer inventory screens.

IU misread as IV (9)
A nurse misunderstood the abbreviation IU (international units) as IV (intravenous) in an order for vitamin E 200 IU.
Recommendation: The term "units" is an acceptable denotation for "international units" and should be used in place of the IU abbreviation.

Non-formulary drugs and safety concerns (11)
Non-formulary medications may be prescribed without fully considering the potential for errors, especially at night or on weekends when staffing is reduced.
Recommendation: Use of non-formulary drugs should be discouraged until they have gone through a formulary addition process. If nonformulary medications are truly needed, a process should be in place to ensure all staff are provided with necessary information before the product is used.

IV infusion of breast milk in neonates (12)
Accidental IV infusion of non-sterile particulate fluid such as breast milk can be fatal. Since enteral pumps cannot deliver feedings in small enough quantities for neonates, parenteral syringe pumps are sometimes used (off label), risking accidental IV administration.
Recommendation: Use non-Luer feeding tubes and extension sets, which are available from several manufacturers. The connectors at the distal end of these sets are female and will only connect to the male connector on the systems' feeding tubes. The side ports only connect to an oral syringe.

Preventing renal failure from contrast media (7)
Radiocontrast-induced nephrotoxicity, a leading cause of hospital-acquired acute renal failure, led to dialysis for an elderly patient. Risk factors for this reaction include diabetes, advanced age, volume depletion, heart failure, cirrhosis, hypertension, and use of drugs that affect renal hemodynamics, such as non-steroidal anti-inflammatory drugs and ACE-inhibitors.
Recommendation: Screen patients for risk factors and hold contraindicated drugs, as needed, before and after contrast administration. For patients with significant risk factors, IV saline is generally recommended at 1 mL/kg/hour for 24 hours beginning 2 to 12 hours before contrast administration.

Two bar codes on one unit-dose package (9)
Although compliant with the FDA bar-code ruling, some manufacturers have applied two bar codes on drug packages (e.g., Duragesic 12 mcg/hour patches), one to identify the NDC number and another for internal quality purposes. This has confused nurses who attempt to scan the product for verification.
Recommendation: Pharmacy may need to relabel some products with an easily identifiable bar code to scan. (Please let ISMP know about problems with bar codes so we can notify companies and advocate for appropriate changes to reduce the need for pharmacy rework.)

Today and Qday (12)
"Qday," used as a substitute for the unapproved abbreviation "QD," has been misread as "Today" (and vice versa). These two terms also sound alike and could be misheard as one another.
Recommendation: Always communicate a frequency of "daily" by writing it out fully.

Dash marks lead to overdoses (13)
A patient received an overdose of vincristine when an order was written as "2 mg IV daily x 8 on day 4-11" rather than "2 mg IV daily on day 4 and 11."
Recommendation: A dash mark should never be used when communicating dosing schedules. Limit vincristine doses to 1.4 mg/m2 per week. Set hard stops in the computer to prevent the entry of unsafe single or cumulative doses. Allow only specifically educated staff to prescribe, dispense, or administer this drug.

IMURAN (azathioprine) and mercaptopurine drug duplication (13)
Mercaptopurine is a metabolite of azathioprine. When taken together, these medications have profound adverse effects. Many drug information sources and computer order entry programs lack warnings of duplicate therapy with concomitant administration.
Recommendation: Test the medication order entry system for a duplicate entry warning and make modifications if needed. Modify reference material lacking a therapeutic duplication warning.

Morphine sulfate immediate-release, concentrated oral solution in plastic ampuls (20 mg/mL) (8)
Once removed from its outer wrap, plastic ampuls of oral concentrated morphine (Ethex) have no identifying features or graduations. Also, for
Recommendation: Pharmacy should dispense patient-specific doses of this drug in labeled oral syringes or purchase this medication in alternative packaging.

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.

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses


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