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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - july - september 2009

From the October 8, 2009 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 2009 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. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP List of High-Alert Medications. 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. Many product-related problems can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

vAPSF offers recommendations for safe post-op opioid administration and monitoring (19)
Problem: The Anesthesia Patient Safety Foundation (APSF) recently published an editorial regarding the continuing problem of opioid-induced respiratory depression. APSF identified inadequate monitoring of oxygenation and/or ventilation, in addition to failure to consider patient-specific characteristics, as causes for the continued occurrence of opioid-induced respiratory depression.
Recommendation:  According to APSF, the following should be addressed in all patients receiving postoperative opioids: 1) Individualize each patient’s dose based on the patient’s history and physical status; 2) Make pulse oximetry routine; 3) Assess each patient’s need for supplemental oxygen; and 4) Consider capnography to monitor ventilation, particularly for patients receiving oxygen and/or at high risk for opioid-induced respiratory depression (e.g., depressed level of consciousness, preexisting respiratory impairment, sleep apnea, and very sick, elderly, or obese patients).

What does a bar-coding scanner beep mean? (19)
Problem: The auditory signal or beep issued by certain hospital point-of-care bar-coding systems to indicate that the scanner successfully read a barcode may be misinterpreted as a signal that the correct patient and drug have been selected, particularly if the computer screen cannot be viewed clearly.
Recommendation:  Evaluate your point-of-care bar-coding system to identify if any auditory signals could be misunderstood. Educate staff regarding the meaning of auditory signals related to bar-coding systems. For vendors of bar-coding systems, consider using different auditory signals to distinguish a correct drug that is scanned from an incorrect drug.

vInsulin errors  (14)
Problem: A renal transplant recipient developed cardiopulmonary instability after receiving 100 units instead of 10 units of regular insulin IV for the treatment of hyperkalemia. An anesthesiology resident drew 1 mL of U-100 insulin into a 10 mL syringe, added 9 mL of saline, and injected the entire contents. Inadequate hospital orientation and training of residents in medication preparation was a key contributing factor.
Recommendation: Develop a medication preparation course and preceptor program for new residents and anesthesia, OR, PACU, and pharmacy staff. In hospitals with OR pharmacy satellites, insulin dilution and dose preparation should occur in the satellite pharmacy, or an insulin minibag system (prediluted to 1 unit/ mL) may be used (however, insulin adherence to plastic IV bags/tubing makes it difficult to estimate exactly how much insulin is reaching the patient).

 Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children (16)
Problem: Two 6-year-old children died from severe postoperative hyponatremia. In the first case, the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in free water retention (also called water intoxication). In the second case, the child received several doses of furosemide and EDECRIN (ethacrynic acid), exacerbating the loss of sodium. In both cases, staff failed to recognize the signs of hyponatremia. Children who receive hypotonic solutions are particularly vulnerable to water intoxication because they are prone to developing syndrome of inappropriate antidiuretic hormone (SIADH), or the excessive release of ADH.
Recommendation: Administration of hypotonic saline or parenteral fluids without saline is physiologically unsound and potentially dangerous for hospitalized children. Thus, standards of practice should be established for postoperative IV solutions used to hydrate patients–particularly children. Protocols should be established to identify, treat, and monitor patients with hyponatremia, water intoxication, and/or SIADH. Consider establishing an interdisciplinary rapid-response team that allows healthcare workers (or patients/families) to summon a clinical team to the bedside for a full evaluation when they fear something is wrong and have expressed their concerns without adequate response.

Safety issues with elastomeric pain relief balls (ON-Q PainBuster and others) (14,15)
Problem: Safety issues have been identified with the ON-Q PainBuster, an elastomeric pump used after surgery to provide pain relief. The pump is usually filled and started in the OR without pharmacy involvement or knowledge. Patients have appeared on units where nurses have never seen the pump. The pain ball has been found unlabeled. Infusion rates may vary due to over- or under-filling of the balls; we’ve received one report of premature emptying of the pump. We have also received reports of using the pump to deliver medications other than local anesthetics, including vancomycin, fentanyl, and morphine.
Recommendation:  Establish standard order sets for prescribing the pump and specific medications. Allow use of local anesthetics only. The Joint Commission defines parenteral solutions in ON-Q pumps as IV admixtures, which should be prepared in the pharmacy except in urgent situations. The pharmacy should use a protocol that specifies the exact amount of solution to instill in the reservoir based on the duration of therapy. Always label the pump (drug, concentration, infusion rate, start date). Other safety strategies can be found at  

vIV promethazine update  (19)
 FDA announced that it will be requiring stronger manufacturer warnings regarding severe tissue damage associated with accidental intraarterial administration or extravasation of IV prometh-azine.
Recommendation: If possible, remove promethazine from the formulary and use alternatives such as 5-HT3 antagonists (e.g., ondansetron) when appropriate. If you MUST keep it on the formulary, administer the drug by deep IM injection only. Avoid IV use. Additional FDA recommendations can be found here .

Scan product, not storage container label (17)
A vial of generic sulfamethoxazole and trimethoprim injection was accidentally placed in a bin for EPI-NEPHrine injection. A technician took this vial from the EPINEPHrine bin and scanned the label on the bin, not the vial itself. The vial was placed in a ziplock bag with a barcode label. A pharmacist checked the item by scanning the barcode on the ziplock bag, not the vial. A technician then placed the item in an ADC, again scanning only the ziplock bag.
Recommendation: To prevent mix-ups of products, scan the product label itself when removing drugs from bins, ADCs, or carousels. The drug storage bin labels should never be used to identify products. 

Name mix-ups between VALTREX (valacyclovir) and VALCYTE (valganciclovir) (17)
ISMP continues to receive reports of mix-ups between Valtrex and Valcyte. The generic names for these two drugs are also strikingly similar, and both the brand and generic names of the products start with the prefix “val.” Both have uses associated with cytomegalovirus (CMV) and may be used in immunosuppressed patients with human immunodeficiency virus (HIV) or transplant patients.
Recommendation:  Consider adding these drugs to your list of look-alike drug names, and take steps to reduce the risk of confusion, including: building software alerts to warn about possible confusion, requiring staff to match the prescribed drug with the patient’s medical history, using both the brand and generic names when prescribing or listing these drugs, requiring read-back of all oral orders, and using tall man letters—valACYclovir and valGANCIclovir—when listing the drugs in computerized inventories.

Name mix-ups between PROVERA (medroxyPROGESTERone), PROZAC (FLUoxetine), and PROSCAR (finasteride) (15)
A pharmacist misread a handwritten order for Provera 10 mg PO daily and dispensed Prozac 10 mg, which the patient received until the next day. The handwritten order was shown to several nurses, pharmacists, and physicians; one person thought the order was for Proscar.
Recommendation:  Consider adding these drugs to your list of look-alike drug names, and take steps to reduce the risk of confusion, including: building software alerts to warn about possible confusion, requiring prescribers to include the drug’s purpose on orders, and requiring staff to match the prescribed drug with the patient’s medical history.

Name mix-ups between KAPIDEX (dexlansoprazole) and CASODEX (bicalutamide) (16,17)
 There have been numerous reports of errors due to name confusion between Kapidex and Casodex with both handwritten and oral prescriptions. ISMP also learned there is a foreign acetaminophen and propoxyphene containing product called Capadex available in Australia, New Zealand, and online.
Recommendation:  Consider adding Kapidex and Casodex to your list of look-alike drug names, and take steps to reduce the risk of confusion, including: building software alerts to warn about possible confusion, requiring staff to match the prescribed drug with the patient’s medical history, requiring prescribers to include the drug’s purpose on prescriptions, and requiring read-back of all oral orders.

Quinine-quinidine mix-ups still happen (18)
 A physician ordered QUALAQUIN (quinine sulfate) 324 mg for leg cramps for a newly admitted patient. The pharmacist selected a 324 mg tablet from a list of products on the computer screen. However, he selected quinidine extended release 324 mg instead of quinine. This error continued for 2 weeks. Fortunately the patient was not adversely affected. Mix-ups between quinidine and quinine are common.
Recommendation:  The only approved indication for quinine is to treat uncomplicated Plasmodium falciparum malaria, (rarely encountered in the US). Quinine should not be available for leg cramps and should be removed from the formulary. If malaria is encountered, access the drug from an outside source. Use tall man letters for quiNIDine and stock it only in the available 300 mg strength (extended release and immediate release).

PENTACEL (diphtheria and tetanus toxoids, acellular pertussis [DTaP], inactivated poliovirus [IPV], and Haemophilus b [Hib] conjugate) (16)
 Pentacel is a 2-vial vaccine product that requires mixing of the two components before administration. Only the DTaP/IPV vial carries the brand name Pentacel. Clinicians may think only the vial labeled Pentacel is needed. ISMP has contacted the vaccine manufacturer to suggest labeling changes.
Recommendation:  Educate staff who will be administering vaccines to children about the need to mix the two vials. If feasible, have pharmacy add auxiliary labeling to the product before dispensing it. Require documentation of the NDC number, lot number, and expiration date for each component in the vaccine log.

Ohio government sentences pharmacist to jail time (17)
Ohio pharmacist Eric Cropp was sentenced to 6 months in prison, 6 months of home confinement, and other criminal penalties for making a human error that caused the death of a child. During an independent check, Eric failed to detect that a pharmacy technician had used too much 23.4% rather than 0.9% sodium chloride as a diluent when preparing a chemotherapy infusion. Human factor research shows that, under moderate stress, we fail to detect an error about 20% of the time.
Recommendation:  Review your procedures for checking pharmacy-prepared infusions of high-alert medications to ensure that the process is reliable. Ensure that technicians preparing IV infusions are well trained regarding the types of products being used and the appropriate use of 23.4% sodium chloride. Whenever possible, use standard, premixed base solutions (such as 0.9% sodium chloride) instead of preparing base solutions by hand. Restrict access to hypertonic sodium chloride vials. Educate staff about human factors and a Just Culture.  

Caution regarding once-weekly levothyroxine   (19)
A recent article suggests that once-weekly levothyroxine may be as effective as daily dosing. This new dosing regimen may lead to errors in which the weekly dose is taken daily. Errors may be difficult to detect since daily administration is the norm, doses vary between patients, and a weekly dose may be the same as a daily dose for some patients.
Recommendation: Provide education to physicians regarding the potential for error with this weekly dosing regimen.  Patient education should include emphasis of the weekly dosing schedule and the potential for a dosing error.


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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