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ISMP Quarterly Action Agenda: July - September, 2000

From the October 4, 2000 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 their facility. The following selected items appeared in the ISMP Medication Safety Alert! between July - September 2000. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information. The American Society of Health Care Risk Management (ASHRM) provides the ISMP Quarterly Action Agenda to all its members. A list of agenda items is also posted on our web site ( In many cases, product-related problems can be visualized in the ISMP Medication Safety Alert! section of our web site. Continuing Pharmaceutical Education is available for the Action Agenda on our web site (

I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • PROSTIN 15 (carboprost tromethamine, HEMABATE), PROSTIN E2 (dinoprostone, prostaglandin E2), and PROSTIN VR Pediatric (alprostadil, prostaglandin E1) (16)
    Problem: Confusion surrounds prostaglandin products when referred to as "Prostin." PROSTIN E2 is a vaginal suppository used to induce labor, treat uterine bleeding and atony, and as an abortifacient. In some European and Scandinavian countries, carboprost tromethamine is known as PROSTIN 15. In the U.S., it's called HEMABATE and used for postpartum bleeding. PROSTIN VR Pediatric is used to maintain patency of ductus arteriosus and is available in 500 mcg ampuls of 1 mL, exactly double the amount available with HEMABATE. Recommendation: Order prostaglandin products using both the generic and brand name. Include "Pediatric" in the brand name field for Prostin VR. Pharmacists should also be aware of the patient's condition and indication for use of a prostaglandin.
  • SARAFEM (fluoxetine) and SEROPHENE (clomiphene citrate) (17)
    Problem: Verbal orders for these two drugs could be confused. Sarafem, a new trademark for fluoxetine approved for premenstrual dysphoric disorder (PMDD), is available in 10 and 20 mg capsules. Serophene is a 50 mg tablet used to treat ovulatory failure.
    Recommendation: Encourage prescribers to include the drug's purpose on prescriptions. Alert patients and caregivers to the potential for confusion between these drugs. When receiving telephone orders, repeat the drug name and spell it back to the prescriber.
  • RETROVIR (zidovudine) and ritonavir (NORVIR) (9)
    Problem: Three pharmacies recently reported dispensing errors with Retrovir and ritonavir. Two patients developed potentially life-threatening anemias after receiving Retrovir instead of ritonavir. Although dosages are somewhat different, both are available in a 100 mg capsule, which increases the risk of confusion. Similar cases have been reported in the past. Recommendation: Prescribers should use both brand and generic names when prescribing these drugs and the names should be printed. Store the products separately and apply warning labels to prevent product misidentification. Alerts in the pharmacy computer system are also helpful.
  • pancuronium and enalaprilat (19)
    Problem: Baxter's vials of pancuronium, a paralyzing agent, and enalaprilat, an antihypertensive, look dangerously similar in appearance. A fatality might occur if pancuronium is given accidentally to a patient who is not mechanically ventilated. Recommendation: Until label changes occur, obtain one of the products from a different manufacturer to make its appearance dissimilar. If this is not possible, separate the storage of these drugs and apply a warning, "paralyzing agent," on pancuronium vials.
  • AVANDIA (rosiglitazone) and COUMADIN (warfarin); TEGRETOL (carbamazepine) and TEQUIN (gatifloxacin) (15)
    Problem: It's easy to confuse newer drugs on the market with older, more familiar drugs when their names are similar. Poorly written orders for the new anti-diabetic, Avandia, have been misread as Coumadin. Both are available as 4 mg oral tablets. Familiarity with the word "equine"invites mispronunciation/misspelling of the new drug, "Tequin" with an "E" at the end of the name, which when scripted, can look like the "L" in Tegretol. Again, overlapping available dosage strengths (200 and 400 mg tablets) make errors more likely. Recommendation: Knowing the patient's diagnoses can help prevent these errors. Thus, nurses and pharmacists should always match the purpose of the drug with the patient's diagnoses before dispensing or administering these drugs. When possible, prescriptions should include the medication's purpose. Using reminders on drug containers and building alerts in computer systems may also be helpful.

II. Discussion Items

  • Pharmacists' review of orders prior to administration (15)
    Problem: It's risky to remove non-critical first doses and other routine medications from floor stock or automated dispensing cabinets if drug administration can safely wait until a pharmacist is able to review and screen the order first.
    Recommendation: Safeguards must be established for the storage, removal, and administration of drugs available in automated and non-automated floor stock. A clear process is needed to determine when an urgent situation would necessitate the administration of a drug stored in patient care units before pharmacy order review. Stock must be carefully selected and provided in limited quantities, single concentrations, and in unit doses. Drugs obtained from stock before pharmacy review should be independently double-checked by a second practitioner before administration. Timely order verification and minimal turnaround time is needed to avoid unnecessary use of floor stock.
  • Use of fibrinolytics to treat acute myocardial infarction (19)
    Problem: When using fibrinolytics and related therapy, any deviation in the dose, timing, or use of specific agents could adversely affect the patient's outcome. Several reported errors demonstrate that complex regimens and variations in the way the drugs are dosed and administered increase the chance of serious errors, especially when multiple products are on the formulary and protocols are absent or poorly designed.
    Recommendation: Limit fibrinolytic agents on the formulary. Use streamlined protocols and standardized order forms to promote proper use. Refer to tissue plasminogen activators by their full generic names, not "t-PA." Simplify the treatment regimen while considering all the associated drugs that may be used and the tight time constraints for administration. Make sure protocols clearly note that a heparin infusion should not be started if a low molecular weight heparin has just been administered. Educate physicians, pharmacists, and nurses when adding new fibrinolytics to the formulary. If possible, have pharmacy dispense fibrinolytics, especially if mixing is necessary. Otherwise, limit the number of doses available in patient care areas.
  • Documentation of a patient's adverse drug reactions (ADRs) (18)
    Problem: Information about ADRs are typically buried within the medical record, poorly visible and difficult to access for all who provide care to the patient. A patient who developed heparin-induced thrombocytopenia in a critical care unit had her IV line flushed with heparin after being transferred to a medical unit because the ADR information was not readily available to staff.
    Recommendation: In addition to documenting ADRs in progress notes, physicians should communicate them in a standardized fashion such as writing them on an order form, similar to prescribing therapy. This quickly communicates the information to nurses and pharmacists and allows them to enter it in appropriate interactive fields in the computer system and in other nursing and pharmacy records. It also facilitates timely discontinuation of the drug suspected to cause an ADR.
  • Problems with automatic stop orders (16)
    Problem: Automatic stop orders may lack specificity and fail to consider "exceptions to the rule" for designated drugs and indications. Examples include warfarin for atrial fibrillation, enoxaparin in patients awaiting cardiac surgery, and phenobarbital for epilepsy. Problems result if orders for these drugs are automatically discontinued by the computer system without warning
    Recommendation: After reviewing your state regulations, evaluate the need to continue enforcing automatic stop policies. If the policy is necessary, identify "exceptions" (e.g., warfarin for atrial fibrillation) and exclude them from the policy. To prevent unintended discontinuation of drugs, encourage prescribers to include the drug's indication and duration and incorporate the duration of drug therapy in diagnosis-specific protocols/standardized orders. Configure computer systems so drugs governed by automatic stop orders are not discontinued without notice.
  • Electromagnetic interference (EMI) with the operation of mechanical device (19)
    Problem: In theory, it's been purported that EMI from cellular phones can affect the proper operation of mechanical devices. Now, an epinephrine overdose has been reported in which a cellular phone in the "standby" mode caused an infusion pump to deliver an unintended bolus dose.
    Recommendation: Ban the use of visitor cellular phones in healthcare facilities or enforce strict guidelines for their safe use.
  • Joint Commission (JC) releases draft patient safety standards (18)
    JC has issued draft standards that support patient safety. A few of the many important standards include: 1) designating one or more qualified individuals to manage the organization-wide patient safety program; 2) clear expectations for internal and external reporting of error information; 3) mechanisms to support staff members who have been involved in a sentinel event; and 4) an annual report to the governing body on actions taken to improve safety.
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