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ISMP Medication Safety Alert

ISMP Quarterly Action Agenda: July - September, 2000

From the October 3, 2001 issue

One of the most important ways to prevent medication errors is to proactively seek and use knowledge from other organizations that have experienced problems to prevent similar occurrences. To promote such a process, administrative staff and an interdisciplinary committee (e.g., Pharmacy and Therapeutics, medication safety teams, process improvement/clinical safety groups, etc.) at each practice site should review the following agenda to prompt discussion and stimulate action to reduce the risk of errors. The following selected items appeared in the ISMP Medication Safety Alert! between July - September 2001. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information as desired. Agenda items are posted on our web site and many product-related problems can be visualized in the ISMP Medication Safety Alert! section. ACPE credit is available for pharmacists (see for details). The American Society of Health Care Risk Management (ASHRM) routinely provides the ISMP Quarterly Action Agenda to all its members.

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

  • LANTUS (insulin glargine [rDNA origin]) and LENTE (insulin zinc suspension) (14) (16)
    Problem: Confusion is possible with verbal or written orders for Lantus, a new once-a-day insulin product with a constant 24-hour blood level, and Lente, a more rapid and shorter acting insulin. Using the letter L as an abbreviation for Lente can also contribute to mix-ups.
    Recommendation: Alert prescribers to potential mix-ups. Prohibit the use of L as an abbreviation for Lente or Lantus insulin and clarify all orders if received in this manner. Remind nurses that Lantus insulin should be given daily at bedtime, not in the morning like other insulins. Place auxiliary warning labels on Lantus vials.
  • SERZONE (nefazodone) and SEROQUEL (quetiapine) (14)
    Problem: Similarities in nomenclature with the antidepressant SERZONE (nefazodone) and the antipsychotic SEROQUEL (quetiapine) has led to 17 reported mix-ups. Poorly written orders, storage near each other, and listing names sequentially on computer screens have been contributing factors. Similar instructions, dose ranges, and availability in 100 mg and 200 mg strengths also heighten the risk of errors.
    Recommendation: Separate product storage and names on computer screens or printed forms. Build computer alerts and affix warning labels to products as appropriate. Advise staff and patients about the potential for confusion.
  • AGGRASTAT (tirofiban) and argatroban (15) (16)
    Problem: Name similarity between Aggrastat and argatroban has led to confusion. In addition, although Aggrastat is an antiplatelet drug and argatroban is a direct thrombin inhibitor, each may be thought of as "anticoagulants." Label confusion also has been reported with argatroban. The carton states "100 mg/mL," but the vial size, 2.5 mL, is listed far away from the concentration. The 250 mg total amount is not specified. Errors are possible if staff concludes that only 100 mg is in the vial.
    Recommendation: Evaluate the potential for confusion before adding either drug to the formulary. Clarify the required drug's purpose prior to dispensing or administering either drug. Provide practitioners with side-by-side comparisons of the drugs for reference. Build computer alerts and place reminders on drug containers and storage shelves. Highlight the volume of the vial size on argatroban drug cartons.
  • ROXANOL (morphine sulfate) (19)
    Problem: Instead of the prescribed 10 mg dose, a patient in a long-term care facility received 10 mL of a concentrated form of ROXANOL (morphine sulfate), 20 mg/mL (200 mg).
    Recommendation: When possible, avoid concentrated morphine solution and use commercially available 10 mg/5 mL or 20 mg/5 mL (especially in unit dose cups). Dispense concentrates only for patients who require higher than usual doses due to severe chronic pain. Affix auxiliary labels to help differentiate the concentrated product and remove it immediately from unit stock once discontinued.
  • NIMBEX (cisatracurium besylate) (16)
    Problem: Nimbex is available in a 20 mg/10 mL (2 mg/mL) multiple dose vial, and a 200 mg/20 mL (10 mg/mL) single dose vial meant for preparing infusions. With almost identical packaging and labeling, mix-ups have been reported.
    Recommendation: Until Abbott Laboratories makes planned label enhancements, draw attention to the different strengths by circling the concentration. If possible, have pharmacy dispense Nimbex infusions to avoid storing the two different concentrations in patient care units.

II. Dangerous abbreviations, confusing dose designations, and other unsafe ways of communicating orders

  • "DTO" (18)
    Problem: "DTO 0.7 mL PO q4h" was interpreted as "tincture of opium, deodorized," which contains 10 mg/mL of morphine. However, the prescriber intended the infant to receive "diluted tincture of opium," or paregoric, which contains 25-fold less morphine (0.4 mg/mL).
    Recommendation: Resist using coined names, contrived abbreviations or other unofficial designations for medications. Establish a policy to prohibit the use of dangerous abbreviations. If tincture of opium, deodorized, must be stocked along with paregoric, differentiate these products by using auxiliary warnings on labels and alerts that appear during the order entry process.

III. Patient identification and education

  • DURAGESIC (fentanyl patch) (19)
    Problem: Patients have been known to misapply fentanyl patches. In a recent case, a confused elderly woman misunderstood directions for use and applied six patches at once "wherever it hurt" on her body, resulting in opiate toxicity.
    Recommendation: Patient selection criteria for fentanyl patch use must include an assessment of the patient's ability to understand information about proper dosing, administration, and disposal.
  • Measurement devices for oral liquids (17)
    Problem: A child died when the cap of a hypodermic syringe used during administration of an oral suspension flew off and became lodged in his throat. The hypodermic syringe was given to the parents to measure the medication. The cap appeared to be part of the syringe, especially since the suspension could be withdrawn into the syringe without its removal.
    Recommendation: Hypodermic syringes should never be used for oral medication administration. Parents should be instructed to use a proper measuring device such as a measuring cup or ORAL syringe. While caps on many oral syringes do not pop off easily, parents and staff should be alerted to ensure removal before administration.
  • Bar code technology (15)
    Problem: Only about 2% of hospitals employ bar code technology to dispense or administer medications.
    Recommendation: Prepare now for future implementation by establishing a comprehensive unit dose system.

IV. Other discussion items

  • Medication errors and human factors (13) (19) While it is widely recognized that system failures cause errors and that well-designed systems and technology offer the best chance of preventing errors, we should devote equal attention to understanding how the human system operates and the conditions that adversely affect its function. Researcher Anthony Grasha, Ph.D., Professor of Psychology at the University of Cincinnati, provides study data on cognitive functions, psychosocial factors that influence performance, and tools to enhance work patterns.
  • Nonpunitive culture and accountability (16) (17) (18) (19) Review and discuss our recent article on a shared model of accountability. Discuss survey findings on the perceptions of a nonpunitive culture. See our website ( and newsletter articles for details.
  • Evidence-based practices (15) The Agency for Healthcare Research and Quality (AHRQ) released a report that listed more than 70 evidence-based practices known to improve patient safety ( The National Forum for Health Care Quality Measurement and Reporting (NQF) will use the AHRQ data to establish consensus to guide agencies that may require hospitals to adopt some or all of the practices. Now is the time to assess these practices and degree of implementation in your organization.

    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.

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