ISMP Quarterly Action
Agenda - July - September 2004
From the October 21, 2004 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 July and September 2004. Each item
includes a description of the medication safety problem, recommendations
to reduce the risk of errors, and the issue number (in parentheses)
to locate additional information as desired. Many product-related
problems can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education
credit is available for pharmacists and nurses.
I. Issues Related to Communication
of Prescribed Medications
II. Issues Related to Medication Delivery
- Fentanyl order miscommunicated (14)
Problem: An order for fentanyl was heard as "5,200
mcg per hour" and read back to the prescriber for
verification. A pharmacist called the physician and learned
that he had prescribed fentanyl "50 to 100 mcg per
Recommendation: When reading back verbal orders,
express doses in single digits such as "5-2-0-0"
to avoid confusion.
- Eliminating dangerous abbreviations (16)
Problem: Achieving compliance with the Joint Commission's
dangerous abbreviation initiative has led to strained
relationships between physicians and nurses/pharmacists
who must call for clarification. Some physicians no longer
return pages in a timely manner.
Recommendation: This effort requires peer-to-peer
interaction and support from hospital and medical staff
leaders. Compliance is also needed on all forms of communication
(e.g., computer screens, drug labels, administration records,
- Misprogrammed PCA pumps (15)
Problem: One patient died and another recovered
after nurses misprogrammed Deltec CADD-Prizm PCS Pain
Control System pumps (model 6101). An unrecognized feature
allowed the pump to default back to a prior setting when
the current setting was not confirmed within minutes.
Recommendation: Perform a failure mode and effects
analysis on any new PCA pump considered for use. Introduce
new pumps in a small setting to ensure that the safety
features are operational. Match the sequence of information
on PCA labels with the information that must be entered
into the PCA pump. Highlight the PCA concentration on
- Inadvertent drug injections into inflation ports
Problem: IV tubing and parenteral syringes can
be connected accidentally to some medical devices that
have balloon inflation ports (e.g., Foley catheters, cuffed
tracheostomy tube, cuffed endotracheal tube, gastrostomy
tube with balloon), thus allowing inadvertent medication
administration or unintended solutions into the balloon.
Recommendation: Clinicians and manufacturers should
work collaboratively to identify error potential through
failure mode and effects analysis when introducing new
tubes and catheters into healthcare systems and, when
the risk of injury to patients is high, affix auxiliary
labels to the inflation ports.
- Syringe of air injected during radiologic procedure
Problem: A patient received a syringe full of
air IV via an automated power injector used to administer
contrast media during a CT scan. The syringe had already
been used on the previous patient. The patient experienced
Recommendation: If you use a power injector, ensure
that only qualified staff are handling the contrast media,
and that there is a consistent process for setting up
the syringes, verifying the syringe contents and patient,
observing the patient during injection, and discarding
the used syringes.
III. Issues Related to Drug Information
- Improvised dosing charts can cause errors (13)
Problem: A patient received nitroglycerin at 200
mcg/minute rather than the ordered 60 mcg/minute when
a handwritten dose conversion chart led to misprogramming
of the pump, primarily because corresponding dosage units
had not been listed for numbers that appeared in two columns.
Recommendation: A formal approval process and
ongoing oversight is needed to ensure standardization
and proper design of dosing tables. With standard concentrations
and commercially available premixed drugs, the process
can be simplified by pharmacy application of computer-generated
or commercially printed labels that include dosing tables.
- Dosing errors with CeeNU (lomustine) (14)
Problem: Serious errors have occurred when CeeNU
is administered daily rather than once every 6 weeks.
Two recent errors, one an order entry error in a hospital,
and the other a dispensing error from a community pharmacy,
led to harm and prolonged hospitalization.
Recommendation: Program warnings to dispense "single
dose only" into order entry systems. Use unit-of-use
dose packs and enhance labels for patients. Require counseling
for every CeeNU dose dispensed. Require initial and ongoing
training for staff who handle oral chemotherapy.
- Don't use immediate-release nifedipine for hypertensive
Problem: The effect of immediate-release nifedipine
in adults is unpredictable, and several well-documented
reports describe serious side effects, from profound hypotension
to death, when this drug is used during a hypertensive emergency,
even if the capsules are swallowed whole (not just sublingual
Recommendation: Alternatives for acute episodes
of hypertension include: oral clonidine, captopril, or
labetalol; enalaprilat IV; or nitroprusside infusion.
- New formulation of CYTOXAN (cyclophosphamide) (17)
Problem: Bristol-Myers Squibb (BMS) has recently
discontinued the lyophilized formulation of the injectable
drug. The new formulation does not contain mannitol so there's
very little powder in each vial. To prevent hypotonicity,
the drug must be reconstituted with sodium chloride rather
than sterile water.
Recommendation: Alert staff to the new reconstitution
directions and amend any drug admixture resources that
contain sterile water as the diluent for cyclophosphamide.
Surgical fires with ethyl chloride continue (17)
Problem: A physician applied ethyl chloride spray
to an area on a girl's forehead, which ignited when a
cautery device was turned on. The container has poorly
visible warnings about flammability. The patient suffered
first-degree burns to her ear.
Recommendation: Reevaluate the need for this product
on your formulary, as there are often safer alternatives,
especially for topical anesthesia. Add auxiliary labels
to warn about flammability.
IV. Issues Related to Drug Labeling, Packaging,
- ACTOS (pioglitazone) and ACTONEL (risedronate) (13)
Problem: A pharmacist entered "ACTO"
into the computer to find ACTOs, but mistakenly chose
ACTOnel on the screen. The patient received the wrong
medication for 16 days.
Recommendation: Match both brand and generic name
to confirm the correct drug has been selected when using
the first few letters of a drug name. Consider adding
- MUCOMYST (acetylcysteine) and MUCINEX (guaifenesin)
Problem: Two patients received the wrong medication
due to mix-ups between Mucomyst and Mucinex. Although
neither patient was harmed, serious injury could occur
if Mucomyst was not administered to treat an acetaminophen
overdose or prevent contrast media induced nephrotoxicity.
Recommendation: Confirm the drug's indication
before dispensing and administering these medications.
- Deadly mix-ups with hydromorphone and morphine
Problem: Instead of morphine 10 mg IM, a patient
received hydromorphone 10 mg (equivalent to 60-70 mg of
morphine). Both drugs were available in the same strength
in a narcotic drawer. These mix-ups are among the most
common and serious with high-alert drugs. This patient
died, as have others.
Recommendation: Reduce or eliminate hydromorphone
from unit stock. Provide these drugs in different strengths
or forms (e.g., prefilled syringes of hydromorphone 1
mg) if both must be available in unit stock. Store each
drug in a separate bin/drawer. Use tall man letters and/or
the brand name, DILAUDID, on labels and computer screens.
While morphine may be available via the override feature
in automated dispensing cabinets, do not allow hydromorphone
to be removed from the cabinet before pharmacy screening
of the initial order.
- NOVOLIN 70/30 (70% NPH human insulin isophane suspension,
30% regular human insulin) and NOVOLOG MIX 70/30 (70% insulin
aspart protamine suspension, 30% insulin aspart) (14)
Problem: Recent mix-ups between Novolin 70/30
and Novolog Mix 70/30 have occurred. In the past, the
more familiar product, Novolin 70/30, was administered
instead of the newer Novolog Mix 70/30 product. More recent
mix-ups have occurred when "Mix" was not included
in orders for Novolog Mix 70/30.
Recommendation: Consider limiting the insulin
analog 70/30 mixtures on the formulary to just a single
product. If both products are available, place reminders
about confusion on storage locations and differentiate
names on labels and computer screens by using tall man
letters (e.g., NovoLIN, NovoLOG MIX).
- Errors continue with conventional and liposomal
Problem: Nurses administered the liposomal form
of doxorubicin, DOXIL, to patients instead of the conventional
form, doxorubicin hydrochloride.
Recommendation: Ensure that nurses who administer
chemotherapy are aware of the potential for this error.
Store the two medications separately in the pharmacy,
and allow only trained pharmacy staff to prepare chemotherapy.
Add auxiliary labels to Doxil containers and storage shelves,
and use the brand and generic names to differentiate the
liposomal form of the drug.
Ratio dose expression confusing (15, 16)
Problem: A 16-year-old with priapism received
an intracavernous irrigation of 4 mL (4 mg) of undiluted
1:1,000 epinephrine. A 1:1,000,000 epinephrine solution
should have been used. The physician thought that the
1:1,000 ratio on the 1 mg/mL vial meant that 1 mg of drug
had been prediluted with 1,000 mL of fluid. The patient
arrested and could not be resuscitated.
Recommendation: Do not stock large vials (30 mL)
of epinephrine 1:1,000. If this concentration is necessary,
stock only the 1 mL ampuls so the need for multiple vials
can serve as an alert. ISMP has petitioned USP, asking
for the elimination of ratio expressions on epinephrine
- Tetanus toxoid and tuberculin purified protein
derivative (PPD) (16)
Problem: The Centers for Disease Control and Prevention
has published a warning about accidental administration
of tetanus toxoid-containing vaccines instead of PPD.
The products have similar names and packaging.
Recommendation: Purchase these products from different
manufacturers whenever possible. Remove tetanus toxoid
and PPD from unit stock if feasible and dispense from
the pharmacy. Affix warning stickers on outer cartons
if both products are available. List the full vaccine
names to prevent confusion.
- AMARYL (glimepiride) and REMINYL (galantamine) mix-ups
Problem: Several reports have described the administration
of Amaryl in place of Reminyl, leading to potentially
Recommendation: Ensure that practitioners are
aware of the risk of mix-ups, especially with handwritten
orders. Confirm that patients are diabetic before dispensing
or administering any antidiabetic medication. FDA and
the drug manufacturers will be taking action to reduce
the risk of errors.
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.