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ISMP Quarterly Action Agenda - April - June 2012

From the July 12, 2012 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 items from the April-June 2012 issues of the ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP’s List of High-Alert Medications ( The Action Agenda is also available for download in a Word format ( that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Many product-related problems can also be viewed in the ISMP Medication Safety Alert! section of our website at: Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

vMismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors (13)
Problem: A physician prescribed PN for a 16-year-old boy (72 kg) using a standard pediatric template that prom-pted orders for most nutrients in per kg units (e.g., mEq/kg). The pharmacy template for patients more than 40 kg required entry of nutrients in per day units (e.g., mEq/day). The pharmacist failed to change the prescribed per kg doses to the per day doses. The patient received an exceedingly hypo-tonic solution (138 mOsm/L) because 2,600 mL of sterile water for injection was used erroneously.
Recommendation: Be sure the templates for prescribing PN and entering orders into the automated compounding device software (or pharmacy computer) match, both in chronological order and measurement units. Use a total daily dose when prescribing nutrients for adults and daily weight-based doses (mg/kg/day) when prescribing nutrients for pediatric patients. Build and heed automated warnings regarding excessive nutrient doses.

vSafe fentaNYL patch disposal (9,10)
Problem: A 2-year-old boy accidentally gained access to a used fentaNYL patch while visiting his great-grandmother in a nursing home. The boy died and the medical examiner found a fentaNYL patch in the boy’s throat. Investigators later found improperly discarded used patches at the nursing home.
Recommendation: A National Alert Network (NAN) warning was issued about proper disposal of fentaNYL patches ( Product labeling states used patches should be flushed down the toilet. Follow-up with the FDA revealed that flushing used patches is intended for disposal in the home. In healthcare organizations, patches may be disposed of in a secure sharps container, and witnessed and documented according to policy. However, some states may have other requirements, so check with DEA and your pharmacy licensing board.

ON-Q PainBuster Post-Op Pain Relief System (I-Flow Corporation) has a Luer connector  (8)
Problem: The ON-Q pump, intended to infuse anesthetic solution around surgical wound sites, incorporates tubing that attaches to infusion equipment with a Luer connector, which is common to IV lines. With bupivacaine and other local anesthetic solutions, patient harm is possible if the ON-Q pump is inadvertently attached to an IV line. 
Recommendation: Affix a label to the ON-Q solution container stating, “Warning: Regional Block Only.” Always trace the solution to the patient access point or vice versa to prevent inadvertent attachment of the ON-Q tubing to an IV access port.

 v Concentrated EPINEPHrine mistaken as lidocaine with EPINEPHrine (7)
Problem: As predicted by the anesthesiologist in our Beyond Blame film who was present 15 years ago when a young boy died after receiving a local injection of EPINEPHrine 1:1,000 instead of lidocaine with EPINEPHrine (1:100,000), mix-ups between these products continue to happen. It is hard to understand why well-known errors like this continue to happen when prevention strategies have been well publicized.
Reccomendation: Supply EPINEPHrine for topical use in a pour-bottle with an auxiliary label that states “TOPICAL.” Or, replace the need for vials of topical EPINEPHrine with presoaked EPINEPHrine pledgets prepared in advance of procedures. Do not place medication intended for injection (e.g., local anesthetic) in an open container (e.g., bowl).

vCovidien ChemoPlus gown may not afford worker protection (12)
Problem: A technician accidentally sprayed iron dextran injection on her ChemoPlus Protective Gown sleeve but it seeped through onto her clothes. While the ChemoPlus product description states that the fabric is “splash resistant,” the gowns do not meet OSHA, ASHP, or ONS recommendations for chemotherapy protection. Only the company’s ChemoPlus Poly-Coated and the ChemoBloc Poly-Coated Gowns meet the recommendations and are appropriate personal protective equipment when handling chemotherapy and other hazardous drugs.
Recommendation: Don’t be misled into believing you are maximally protected during preparation and administration of chemotherapy and other hazardous drugs by the brand name “ChemoPlus.” If you are using ChemoPlus gowns, be sure they are poly-coated and meet OSHA, ASHP, and ONS recommendations. 

vHarm associated with drug shortages (8)
 According to our recent survey, drug shortages—particularly with DOXOrubicin, fentaNYL, morphine, electrolytes, antibiotics, phentolamine, and phytonadione—have extracted a significant toll on patient safety during the past year. The most often cited problems involved suboptimal treatment from use of an alternative medication that was not the drug of choice, errors with alternative medications, and errors when a pharmacy attempted to compound a product or strength no longer available.
Recommendation: When faced with a drug shortage, conduct a mini failure modes and effects analysis (sample format at: to assess the potential hazard to patients and potential misuses of alternative products. Determine how to best manage the risk of serious errors and adverse reactions to alternative drugs, and make any necessary procedural and technological changes to support safe use. When possible, have pharmacy prepare and dispense alternative drugs in the most ready-to-use form. Additional guidance during drug shortages can be found at the above link.

Proper use of single-dose vials (9)
Use of single-dose or single-use vials for multiple patients can lead to contamination and spread of life-threatening infections and is, thus, not recommended, as reiterated by the Centers for Disease Control and Prevention (CDC) in response to concerns that such a policy contributes to drug shortages (
Recommendation: It is imperative that drug shortages and drug waste concerns are dealt with appropriately and that single-dose or single-use vials are used as intended. However, the CDC notes that shortages of some essential medications may warrant pharmacy repackaging to subdivide contents of unopened single-dose/single-use vials via implementation of meticulously applied practice and quality standards following USP Chapter <797>.

vHigh-alert medications left behind by contracted services (9)
A 20,000 units/mL heparin vial was found in a hospital’s operating room despite a decision to not stock this unsafe concentration. It was determined that an organ harvesting team had left the unused vial behind. In another case, a hospital-contracted renal transplant service left sodium chloride 23.4% (used to reduce cramping during hemodialysis) on several nursing units. Staff unaccustomed to the atypical stock can mistake the products for less concentrated forms of the drugs.
Recommendation:  When outside groups contract to provide services, hospital leadership must work with the pharmacy to ensure that the medications and dosage forms that might be used are reviewed and agreed upon by the pharmacy. At that time, alternative products may be discussed and/or arrangements made to securely store products normally unavailable at the hospital. Pharmacy staff should also conduct regular visits to patient care units to observe drug storage.

ASEPT Drainage System (B. Braun Interventional Systems) has Luer connector  (11)
With the Asept drainage system for pleural effu-sions and malignant ascites, a secure connection is made between the catheter and a vacuum bottle that collects the drainage via a Luer lock. It’s possible for the drainage catheter’s female Luer connector to be inadvertently connected to the male end of IV tubing or a syringe of medication instead of the vacuum bottle tubing.
Recommendation: The manufacturer is now printing DRAIN ONLY on the valve and a red end cap provided with the tubing. Hospitals should also label the end of the drainage catheter, and roll up excess tubing (including the female Luer connector) and shield it under a dressing when not in use. Trace all line attachments from the source to the patient or vice versa.

vCenters for Medicare & Medicaid Services (CMS) citing reuse of insulin pens (11)
In May, CMS announced that hospitals will be cited if surveyors identify sharing of insulin pens ( Regurgitation of blood into the insulin cartridge after injection risks disease transmission if the pen is used for more than one patient, even if the needle is changed.
Recommendation: Educate practitioners who administer medications via pens about the risks associated with sharing pens (CMS announcement suggested that some may not be aware of this risk). Dispense pens for individual patients, with a pharmacy label that includes the patient’s name.

IV acetaminophen and overdoses in kids (8)
A clinician accidentally programmed a pump to deliver 250 mL (2,500 mg) of IV acetaminophen instead of 25 mL (250 mg). The error was detected when the nurse called the pharmacy for additional 100 mL vials to administer the dose. Misprogramming the dose in mL instead of mg has also been reported in Europe, where the drug has been on the market longer than in the US. 
Recommendation:  Administer IV acetaminophen using a smart infusion pump with maximum dose settings identified and active in the drug library. Require pharmacy preparation of IV acetaminophen doses that are less than the 1 g strength of the commercially available product. Labeling notes the solution is stable for 6 hours, but the com-pany provided ISMP with written attestation that the solution is stable for at least 24 hours.

vPRADAXA (dabigatran etexilate) and PLAVIX (clopidogrel) mix-up (10)
Plavix was mistakenly dispensed in response to an order for Pradaxa. Plavix is available in 75 mg and 300 mg tablets (usual dose 75 mg daily), and Pradaxa is available in the US in 75 mg and 150 mg capsules.
Recommendation:  Use signs or reminders on shelves in storage areas to warn staff of the look-alike drug name risk to help prevent mix-ups.

Dr. Leape and colleagues call for a culture of respect (12)
Bullying, incivility, and other forms of disrespectful behavior are rampant in healthcare. Focusing on disrespectful physician behavior, Dr. Leape and colleagues, who recently published articles in Academic Medicine, classify the behavior into six categories: disruptive behavior; humiliating or demeaning treatment; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect. The authors suggest that the widespread disrespect that persists in healthcare is a substantial barrier to patient safety progress. 
Recommendation:  Responsibility for addressing disrespectful behavior in the clinical setting belongs to organizational leaders, who need to: raise awareness of the problem; create a sense of urgency to change; revise policies that affect hours, workloads, and mitigation of physical risks; establish a code of conduct and details for managing disruptive behaviors; address systemic issues such as environmental stressors that cause disrespectful behavior; and create a learning environment where medical students are mentored with mutual respect. 

Apothecary measurement system a factor in medication errors (12)
A nurse gave a patient 5 drams (18.45 mL, 1.845 g) of acetaminophen concentrate liquid (100 mg/mL) instead of 5 mL. The dose was measured in a cup with scales labeled in drams, fluid ounces, cc, mL, tsp, and tbsp. Confusion has been reported frequently between drams, ounces, mL, tsp, and tbsp.
Recommendation: ISMP supports complete adoption of the metric system for prescribing and measuring liquid doses. The hospital should use oral syringes or dose cups without apothecary gradations to measure and administer oral liquid medications.

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

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