ISMP Quarterly Action
Agenda: April - June, 1999
From the July 14, 1999 issue
One of the most important methods for preventing adverse
drug events is for organizations to be proactive by seeking
and using knowledge from other organizations that have already
experienced problems. To make a significant impact on error
prevention efforts, administrative staff and an interdisciplinary
committee at each practice site should review the following
agenda to prompt discussion, and then take the necessary action
to minimize adverse drug events in your facility. The following
selected items appeared in the ISMP Medication Safety Alert!
between April and June, 1999. Each item includes a description
of the problem, recommendations for safe medication practices
and the issue number (in parenthesis) to locate additional
information. The American Society of Health Care Risk Management
(ASHRM) provides the quarterly ISMP Action Agenda to all its
I. Look-alike/sound-alike drug names, ambiguous or
look-alike labeling and packaging
- ACTIQ (oral transmucosal fentanyl citrate) flavored
sugar lozenge with an attached handle (7)
Problem: Actiq, used to manage breakthrough pain
in opiate tolerant patients, resembles a "lollipop." The
product could be fatal if children mistake it for candy
or if used by adults who are not already taking opioid narcotics.
Recommendation: Pharmacists and home care/hospice
nurses should educate patients and family members to avoid
referring to the drug as a "lollipop" or "candy" and to
eliminate possible access by anyone other than the patient.
- Alcohol, formalin, and methadone confused with distilled
or tap water (7), (11)
Problem: Several cases have been reported where amoxicillin
was reconstituted with 50% alcohol solution, methadone,
or formalin instead of water. In all cases, the chemicals
and methadone were stored near look-alike containers of
Recommendation: Discard chemicals that have not been
used in years. Store those that must remain away from drugs
and drug supplies. Place warning labels on those that look
like other products. Label and bottle methadone distinctly
and segregate it from other drugs. Pharmacies should not
be distributing chemicals to laboratories.
- CELEBREX (celecoxib), CEREBYX (fosphenytoin),
and CELEXA (citalopram) (1), (3), (4), (7), (8),
Problem: Over 100 errors have been reported with
Celebrex, due primarily to confusion with Cerebyx and Celexa.
Recommendation: Encourage physicians to include the
drug's indication when prescribing these products. Restrict
verbal orders to emergency situations with Cerebyx. When
used, spell the drug name back to prescribers. Build alerts
in the pharmacy computer system. Remove Cerebyx from floor
stock and have pharmacists dispense it when prescribed.
Educate patients to understand the name and purpose of these
products and to carefully check that prescriptions are filled
accurately. Consider using an alternate product instead.
ISMP continues to urge FDA and Celebrex's manufacturer to
change the current brand name.
- Chlorpromazine and chlorpropamide (10)
Problem: One patient died and another developed serious
symptoms after receiving 750 mg of chlorpropamide instead
of 75 mg of chlorpromazine daily. The prescriptions were
filled with chlorpropamide, 250 mg, with directions to take
three tablets daily.
Recommendation: Place warnings on drug containers
and storage bins. Build alerts in the computer system and
design mnemonics to prevent the names from appearing simultaneously
on the screen. Assure that drug indication matches patient
- BENTYL(dicyclomine) (9)
Problem: Practitioners are likely to believe that
Bentyl ampuls (Merrell Pharmaceuticals) contain a total
of 10 mg instead of 20 mg, as the ampuls are labeled 10
mg/mL but the 2 mL total volume is not listed.
Recommendation: Until the manufacturer changes the
label, add warnings to alert practitioners to the total
- Infants' TYLENOL (acetaminophen) concentrated drops
and children's acetaminophen elixir (12)
Problem: A nurse administered 10 mL (1,000 mg) of
Infants' Tylenol concentrated drops (100 mg/mL) instead
of children's acetaminophen elixir (160 mg/5 mL).
Recommendation: Use McNeil Consumer Healthcare's
new SAFE-TY-LOCK container for Infants' Tylenol concentrated
drops. Its design allows the dropper to be inserted, but
its one way valves make it difficult to pour teaspoon doses.
- CIPRO (ciprofloxacin), TAXOTERE (docetaxel),
and ROTASHIELD (rotavirus vaccine, live, oral) (11)
Problem: Each of these products contains diluent
vials that emphasize the name of the active drug - not the
fact that it is only the diluent. As a result, product diluent
has been dispensed accidentally instead of the final reconstituted
Recommendation: ISMP has asked FDA and the companies
to de-emphasize the drug name and prominently label the
vial as diluent. Until then, add auxiliary reminder labels
to shelf cartons.
- Jury verdict finds hospital grossly negligent for stocking
concentrated sodium chloride in NICU(13)
Problem: An infant suffered permanent hand scarring
after he was mistakenly injected with concentrated sodium
chloride. The jury awarded the infant and parents $85,000,
citing that concentrated sodium chloride should not have
been available in NICU.
Recommendation: Remove all forms of concentrated
sodium chloride from patient care areas and have pharmacy
dispense these solutions as ordered.
- Repeated errors with penicillin G benzathine (13)
Problem: Another child received penicillin G benzathine
IV. Widespread knowledge deficits about using the drug "IM
only" and remote placement of the manufacturer's warning
contribute to errors.
Recommendation: Provide ongoing education about this
error-prone drug to all practitioners involved in medication
use. Apply bold warning labels on syringe barrels before
stocking/dispensing the drug.
II. Misinterpretation or miscommunication of drug orders
- Numbering orders (7)
Problem: Numbered medical orders may be misinterpreted
as the number of tablets/doses to be administered.
Recommendation: Circle numbers used for listing orders
or avoid numbering orders at all, even on preprinted ordered
- Lack of space between drug name and dose (9)
Problem: A handwritten order for "cisplatinol (sic)
75 mg/m2" was subsequently typed as "cisplatinol75 mg/m2."
The last letter (l) was misread as part of the dose. The
patient received 175 mg/m2 and suffered hearing loss and
acute renal failure.
Recommendation: Review all preprinted orders, drug
protocols, computer-generated MARs and label formats to
assure spaces are appropriately placed between drug names
and doses. Use only approved generic names (cisplatin, not
- Misplaced decimal point (9)
Problem: A patient received 5 mL of fentanyl (0.25
mg or 250 mcg) instead of 0.5 mL (25 mcg) after a nurse
mentally misplaced the decimal point when converting the
milligram dose expressed on the label with the ordered dose
Recommendation: Consider using morphine as the preferred
opiate for intermittent pain control. If fentanyl must be
used, design dosing charts. Have pharmacy prepare PCA doses
and develop protocols to guide safe dosing and administration.
- Ordering by volume, not weight (9)
Problem: An order for ferrous sulfate "1 dropperful
3 times daily" led to confusion about the intended dose,
especially since practitioners or consumers may vary in
their interpretation of a "dropperful" and droppers supplied
with various ferrous sulfate products have differing measurement
Recommendation: Prescribe drugs by weight, not volume.
Express both mg weight and volume on prescriptions and MARs
since measurement devices may include only volume calibration
marks. Use the measurement device included in the package.
- Transcription error on discharge summary (10)
Problem: Reliance on a mistranscribed discharge summary
led to an order for SYNTHROID (levothyroxine), 0.5 mg, when
the patient was actually taking 0.05 mg.
Recommendation: Encourage prescribers who are unfamiliar
with patients to contact family physicians, internists and
community pharmacies for accurate drug therapy information.
When transcribing discharge summaries, use current MARs
and clearly enunciate and spell all drug names. Promote
timely and careful physician review of all discharge summaries.
- Unclear communication of orders using a felt tip pen (13)
Problem: A COUMADIN (warfarin) dose duration
of 2 days was misinterpreted as 7 days when the prescriber
used a felt tip pen and the bottom of the numeral 2 failed
to carry through to the carbon copy.
Recommendation: Remind prescribers to use a ball
point pen to write orders on multiple copy forms.
- Misinterpretation of apothecary measurements (13)
Problem: A patient received phenobarbital 0.5 grams
(500 mg, obtained from 4 x 130 mg unit dose syringes) IV
daily for three days instead of 0.5 grains after the prescriber
misread the apothecary dose listed on the patient's prescription
Recommendation: Only the metric system should be
used when prescribing and labeling drugs. Educate practitioners
that needing more than 2 or 3 dosage units could signal
- Misread checkmarks used to order drugs on preprinted order
Problem: A pharmacist misread a checkmark on a preprinted
prescription form that listed twelve different eye products.
TOBRADEX (tobramycin and dexamethasone) was dispensed
instead of TOBREX (tobramycin) (listed on the line
above) and the child suffered steroid-induced glaucoma.
Recommendation: If using preprinted order forms that
allow prescribers to check a box to order the drug and/or
fill in a dose, assure that look-alike drug names do not
appear near each other.
III. Medication delivery device problems
- Check valves on IVAC administration sets may be difficult
to prime (12)
Problem: Some check valves used for piggybacking
with IVAC administration sets may be difficult to prime.
Problems may also be encountered with other IV sets, as
the same check valve vendor provides materials for other
Recommendation: Until Alaris (markets IVAC devices)
makes corrections, squeeze the IV bag or firmly tap the
check valve against a hard surface to open it. Otherwise,
attach an empty sterile syringe to the injection port below
the valve, clamp the tubing, and aspirate using the syringe.
Place directions for opening the valve with administration
- Amber oral syringes pose potential risks (11)
Problem: Using amber oral syringes heightens the
potential for error as the volume contained in the syringe
is difficult to see and the solution's color is not visible.
Empty amber syringes have been labeled and dispensed as
if there were medication inside.
Recommendation: Encourage the use of clear oral syringes
(not hypodermic syringes) for oral liquid drugs. Light sensitive
preparations should be placed in USP compliant, ultraviolet
light protecting sleeves. Label both the sleeve and syringe.
- Multiple infusion lines, dual chamber pumps and look-alike
IV solutions (13)
Problem: Magnesium sulfate overdoses occurred when
multiple infusion lines on a dual chamber pump were mixed
up (magnesium sulfate restarted instead of oxytocin) and
when IV solutions were misidentified (magnesium sulfate
hung instead of Ringer's lactate).
Recommendation: Use single chamber pumps for high
alert drugs such as magnesium sulfate, label IV tubing near
its juncture with the pump, physically trace the tubing
from the IV bag to the pump, and establish a system of independent
double checks when adjusting rates or hanging solutions.
Provide magnesium sulfate in containers that differ in size
from other common labor and delivery solutions.
IV. Miscellaneous errors and adverse drug reactions
- Stress from making an error may contribute to other immediate
Problem: After administering VERSED (midazolam)
to the wrong patient, an anxious practitioner, intending
to administer ROMAZICON (flumazenil), accidentally
administered ZOFRAN (ondansetron) to the patient.
Recommendation: Take into account the amount of stress
that practitioners undergo upon realizing their involvement
in a serious error and, whenever possible, have another
practitioner provide additional treatment, as indicated.
- Incorrect dose calculation and lack of double checking
Problem: A prescriber incorrectly calculated a dose
of methylprednisolone, but included the mg/kg dose in the
written order. Failure to double-check the physician's calculated
dose led to a patient receiving a massive overdose.
Recommendation: Encourage prescribers to include
the mg/kg or mg/m2 dose with the calculated dose and require
nurses and pharmacists to mathematically double-check the
physician's calculated dose and initial the order form.
Pharmacy computer systems should be effectively designed
to alert practitioners to subtherapeutic or excessive doses.
- "Rule of 6" not optimal for patient safety (11)
Problem: Calculation errors, nursing IV admixture
errors, inconsistent use of the rule, and fluid overload
are a few examples of problems that have occurred when nurses
rely on the "rule of 6" to calculate pediatric critical
care drugs dosed in mcg/kg/min.
Recommendation: Standardize concentrations for pediatric
critical care drugs and use commercially available premixed
solutions or pharmacy prepared products. Provide nurses
with mcg/kg/min dosing charts and make them available on
preprinted solution labels.
- Incorrect label instructions (9)
Problem: Accidentally touching the letter "f" instead
of "g" resulted in a drug label which read "five ¼ teaspoonful"
instead of "give ¼ teaspoonful." Also, adding an unnecessary
verb to directions for a coal tar bath ("take four capfuls
in bath") led to a patient swallowing the product meant
for dilution in bath water.
Recommendation: To detect order entry errors, keep
the original prescription and typed label together during
the dispensing process and review directions out loud with
the patient. Use verbs in directions only when necessary
for correct interpretation.
V. Discussion Items
- Potential error analysis by Pharmacy & Therapeutics (P&T)
Problem: When adding new formulary drugs, P&T Committees
may consider cost, efficacy, and serious adverse drug reactions
(ADRs). Yet, the drug's potential for error may not be fully
anticipated and considered.
Recommendation: Include error potential as a standing
discussion item for all new drugs considered for formulary
inclusion. Establish guidelines or restrictions for those
with heightened error/harm potential and educate staff before
using the drugs. Search the literature for at least six
months to identify errors or ADRs that may have been reported
since product launch.
- The "five rights" of medication use (right patient, drug,
dose, route, time) (7)
Problem: The "five rights" are goals of safe medication
use, not procedural guidelines for practitioners. They focus
on individual performance and fail to acknowledge the significant
contribution of human factors (e.g., confirmation bias)
when errors are made.
Recommendation: Avoid simply admonishing practitioners
who make an error for not following the "five rights." Instead,
help practitioners achieve these goals by establishing strong
support systems and processes that encourage safe medication
- Proactive root cause analysis (8)
Problem: Many hospitals wait until a sentinel event
to perform their first root cause analysis.
Recommendation: Test your root cause analysis process
now so that you can function well in an actual emergency.
As an added benefit, performing such analyses on "near misses"
will provide you with considerable opportunities to improve
- Rapid expansion of clinical services may outpace adequate
planning for safe medication practices (9)
Problem: Pharmacy supplied a newly established pediatric
emergency department with 5 mL vials of Ketamine, 100 mg/mL
(500 mg), instead of the 5 mL, 10 mg/mL vials the newly
hired emergency staff used at another ER. A physician administered
the total vial contents (500 mg), instead of 50 mg, when
sedating a child.
Recommendation: When establishing new hospital services,
devote adequate time to identify and remedy potential areas
of weakness. Ensure proper staff training and appropriate
staffing levels in proportion to the new workload for all
- Current public-policy discussions explore various types
of national reporting programs (10)
Problem: While a mandatory reporting program may
yield larger numbers of actual errors, hazardous situations
that have the potential to cause harm may not be reported.
Further, a mandatory program is unlikely to yield much new
information beyond what can be learned from the current,
streamlined voluntary reporting program, the USP Medication
Error Reporting Program (MERP). Rather than more data, effective
action must be taken on problems that have already been
identified and will continue to be identified through the
current voluntary program. Prior experience with state-mandated
reporting programs has identified numerous problems, including
a punitive focus (to identify dangerous practitioners and
punish those who fail to report), which discourages reporting
and in-depth evaluation of system-based causes of errors.
Recommendation: Non-punitive and confidential voluntary
reporting programs tend to provide more useful information
about errors, system-based causes of errors, and effective
remedies. Resources should be directed toward expanded use
of the current non-punitive, voluntary USP MERP and authoritative
oversight of system-based safe practice recommendations
by JC, state, and federal healthcare agencies.
- Medication error prevention "toolbox" (11)
Problem: Selecting the best error prevention strategy
is not easy. Often, the most effective action is not clear.
Recommendation: Select high-leverage error prevention
strategies that fix the system (forcing functions, constraints,
automation, etc.). Place less reliance on those that attempt
to fix people (rules, policies, staff education, etc.).