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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - July - september 2008

From the October 23, 2008 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 July-September 2008 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. The items with the highest priority appear at the beginning half of the agenda. Many product-related problems can also be visualized in the ISMP Medication Safety Alert!╥section of our website at 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. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

v Epidural bupivacaine given IV leads to fatalities (13)
Problem: Epidural infusions with bupivacaine have been accidentally administered IV—particularly to women in labor—resulting in fatalities. A Black Box warning for bupivacaine notes the drug can cause profound disturbances in cardiac rhythm and contractility that are resistant to typical resuscitation efforts.
Recommendation: Consider use of other epidural agents that may be less toxic than bupivacaine. Ensure delivery of the correct epidural medication to the correct unit, immediately before use if possible. Affix colorful labels to bags and syringes that contain epidural medications stating “For epidural use only.” A checklist of recommendations appear at:

v Intrathecal administration of IV vindesine causes fatality (16)
Problem: A young man with lymphoma died after accidental intrathecal administration of IV vindesine, an investigational chemotherapy agent. Any of the vinca alkaloids (vinBLAStine, vindesine, vinorelbine, and vinCRIStine) can cause fatal neurological effects if given intrathecally instead of IV.
Recommendation: Vinca alkaloids should never be in the same treatment room as intrathecal medications. Also, dilution of vinca alkaloids in an infusion bag is highly recommended to reduce the risk of confusion with intrathecal medication in syringes. Dilution also provides a volume too large for intrathecal administration.

v Misprogramming PCA concentration leads to dosing errors (17)
Problem: ISMP has received reports of overdoses with patient controlled analgesia (PCA) due to misprogramming the concentration of the narcotic. Accidentally programming a lower concentration than actually in the pump, results in the delivery of a higher dose than prescribed since more volume will be infused. The resulting “low concentration” alert from smart pumps has been misinterpreted as a “low dose” alert, which is more common when titrating drugs before discontinuation.
Recommendation: Assess vulnerability to this type of error. Clarify any confusion regarding the inverse relationship between dose and concentration, and the differences between “low concentration” and “low dose” alerts. Limit the number of standard concentrations for PCA drugs. If custom concentrations are needed, use distinctive labels to distinguish it from a standard concentration. Express the concentration of the drug in the same manner it needs to be entered into the pump (mg/mL or total drug/total volume) on the label and medication administration records.

v Heparin errors continue despite prior, high-profile, fatal events (14)
Problem: As many as 17 infants received 100 times more heparin than intended after incorrect preparation in the pharmacy. Other recent neonatal heparin dosing errors have been caused by the presence of unfamiliar heparin strengths in the hospital due to the heparin recall; failed verification processes during preparation or administration; and variability in the strength of heparin used to maintain line patency
Recommendation: Employ validation processes when preparing neonatal heparin products, such as barcode technology, refractometry readings (which should be as low as the diluent alone since the heparin concentration used for neonates is low), or manual double checks. Outsourcing the preparation of neonatal heparin flush syringes is another option. Use preservative-free prefilled heparin flush syringes when available.

v Look-alike bag of diltiazem placed in ZOSYN (piperacillin and tazobactam) stock upon return to pharmacy (13)
Problem: A pharmacy-prepared admixture of diltiazem labeled as Zosyn was almost administered to a patient, risking serious harm. The diltiazem had been prepared for another patient and returned to the pharmacy long after the patient’s discharge, along with another patient’s similar-looking bag of Zosyn. The diltiazem bag was accidentally returned to the Zosyn bin in the pharmacy.
Recommendation: Evaluate the process for returning discontinued drugs to the pharmacy and replacing them in stock to ensure timeliness and accuracy. The safest strategy is to use barcode technology when returning medications to stock, and to return medications to the pharmacy promptly after patients have been discharged.  

Use of tall man letters is gaining wide acceptance (15)
Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish, resulting in fewer errors among products with look-alike names. In a survey of readers, two-thirds (64%) reported that tall man lettering has actually prevented them from dispensing or administering the wrong medication.
Recommendation: Tall man letters should be used to differentiate a standard set of look-alike drug name pairs on pharmacy-generated labels, drug selection screens, shelf labels, medication administration records, and order sets. To promote standardization, ISMP suggests following the tall man lettering scheme provided by FDA and ISMP for the standard drug name pairs (

Medication reconciliation and patient education needed to lessen fatal medication errors in the home (15)
A review of US deaths between January 1983 and December 2004 showed a 360.5% increase in fatal medication error (FME) rates in the home. FMEs in the home where alcohol and/or street drugs were involved increased by 3,196%, while those not associated with alcohol increased by 564%.
Recommendation: Consumers need to be aware of the potential for harm with prescription and OTC drugs, especially when combined with alcohol and/or street drugs. Medication reconciliation upon hospital admission and discharge, and education of patients about their home medications before discharge can play a role in lowering these staggering statistics.

v Proper positioning of pharmacy label on Hospira pumps will avoid interference with scanning (16)
The Hospira LifeCare PCA pump has a barcode scanner to identify prefilled drug vials loaded in the pump. FentaNYL and HYDROmorphone are not available in prefilled vials, so pharmacies must pre-pare these drugs in empty glass vials with a pre-printed barcode that the pump recognizes, enabling it to start. If not placed properly, the pharmacy-applied label can prevent the pump from reading the barcode and starting the pump. One patient received an overdose of fentaNYL while a nurse was trying to manipulate the vial to start the pump.
Recommendation: Companies such as Ameridose and PharMEDium provide outsourced pharmacy compounding of fentaNYL and HYDROmorphone with labels that can be read by Hospira PCA pumps. When a pump malfunctions or difficulty is encountered setting up the pump, staff should be educated to first clamp the tubing to prevent accidental administration during manipulation of the pump. Hospira offers instructions on how to produce and apply pharmacy labels correctly so the barcode can be read by the pump.

v SHRINKSAFE ID Bands make vials look similar (13)
A vial of succinylcholine was found in a bin of vecuronium. Both products were enclosed in ShrinkSafe ID Bands. The Bands help identify paralyzing agents but make the vials look similar. Mix-ups can affect hemodynamic response given differences in the drugs.
Recommendation: Use ShrinkSafe selectively and minimize the variety of neuromuscular blocking agents stored in clinical areas.

v JANTOVEN (warfarin), JANUVIA (sitaGLIPtin), and JANUMET (sitaGLIPtin and metFORMIN) (16)
Jantoven, Januvia, and Janumet have been confused with each other. SitaGLIPtin is available in 25, 50, and 100 mg strengths, which is outside warfarin’s dosage range. But errors are possible if a decimal point is overlooked when prescribing Jantoven 2.5 mg, or if using a trailing zero when prescribing 5.0 or 10.0 mg.
Recommendation: Confirming the diagnosis for patients taking any diabetes drug or warfarin can help to reduce errors if prescriptions for these medications are initially misread. For further recommendations for preventing name mix-ups, see:

v EPINEPHrine and ePHEDrine mix-ups (16)
A nurse misheard a telephone order for ePHEDrine as EPINEPHrine. In addition to name similarities, the drugs have also been confused during selection of the product. Each drug is used as a vasopressor and vasoconstrictor, so storage is often near one another in the same clinical environment. Both products also may be packaged alike in 1 mL ampuls or vials.
Recommendation: Use prefilled EPINEPHrine syringes and keep large vials of the drug out of clinical areas to reduce the risk of preparing large amounts. To prevent mishearing drug names, require “read back” of oral orders. Have pharmacy prepare all infusions and bolus doses except in emergencies. Use tall man lettering on computer inventory listings, shelf labels, and other places where the drug names are expressed.

v Caution when changing infusion duration on some infusion pumps (19)
With some smart pumps, once the medication and dose per hour have been programmed, the infusion rate, volume to be infused (VTBI), and time are automatically calculated and appear in the correct fields. But if the nurse changes the infusion time—from 1 hour to 30 minutes, for example—the VTBI changes rather than the rate of infusion, risking partial administration of medication.
Recommendation: Smart pump drug libraries should be programmed with the most common standard times for infusing medications (e.g., 30 minutes, 1 hour). Staff should be warned about the potential for this error, and each entry on the pump confirmation screen should be rechecked before starting the infusion.

CATHFLO  ACTIVASE (alteplase; available in 2 mg lyophilized powder vials) and ACTIVASE (alteplase) (17)
During a code in the cardiac catheterization lab, a pharmacist called the pharmacy and asked for “t-PA.” The pharmacy staff thought the drug was needed to help restore central venous catheter function and dispensed a 2 mg/2 mL syringe of Cathflo Activase instead of the intended 100 mg dose of Activase.
Recommendation: Complete orders (i.e., dose, route, administration directions, in this case) should always be communicated, and pharmacy should not dispense medications without full prescribing information. In non-urgent cases, using disease-specific protocols and order forms would reduce the possibility of errors.

v Sodium phosphates overdose after recent process changes and implementation of smart pumps (18)
A technician mixed a dose of sodium phosphates using an old procedure, forgetting that the hospital had switched to standard concentrations for infusions since eliminating the rule of six and implementing smart pumps. The admixture contained 501 mmol instead of 25 mmol. The error was not detected and the child died. Inadequate preparation for the switch to smart pumps played a part in the error.
Recommendation: A technician mixed a dose of sodium phosphates using an old procedure, forgetting that the hospital had switched to standard concentrations for infusions since eliminating the rule of six and implementing smart pumps. The admixture contained 501 mmol instead of 25 mmol. The error was not detected and the child died. Inadequate preparation for the switch to smart pumps played a part in the error.

Mix-up between lactated Ringer’s and oxytocin (18)
A woman in labor received an unspecified amount of IV oxytocin when her nurse thought an infusion bag contained lactated Ringer’s, resulting in emergency delivery of the baby. Distracted by the activity in the room, the nurse had failed to properly identify the infusion bag before hanging it.
Recommendation: IV bags of oxytocin should be prepared in the pharmacy and boldly labeled to differentiate it from lactated Ringer’s. Create designated areas to place medications needed during different phases of the labor and birth process (e.g., boldly labeled containers where the products can be placed in an organized manner). Use of point-of-care barcode technology can also help ensure that the right product has been selected for administration.

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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