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ISMP Quarterly Action Agenda -july-september 2010

From the October 7, 2010 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 2010 issues of the 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 viewed in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for nurses at:       

Key: v  — ISMP high-alert medication

DTaP-Tdap mix-ups now affecting hundreds of patients (13)
Problem: The ISMP Medication Errors Reporting Program (MERP) database contains hundreds of cases of mix-ups between adult and pediatric products used to immunize patients against diphtheria, tetanus, and pertussis. These products are easy to confuse due to their similar names and abbreviations (DTaP-Tdap). An infant/child who receives Tdap instead of DTaP would receive an inadequate dose of antigen.      
Recommendation:  Educate staff about the risk of confusion. Separate the pediatric and adult formulations in storage areas. Encourage prescribers to order the vaccines by brand name, not vaccine abbreviation. Document the vaccine and lot number on the vaccine form/log just prior to administration (document administration after the vaccine has been given). Ask parents or caregivers to assist with verification of the vaccine before it’s administered.

Preventing catheter/tubing misconnections (14)
Problem: Catheter/tubing misconnections remain a serious problem in healthcare. Luer connector systems, common to many healthcare catheters, tubes, and syringes, pose the greatest risk.
Recommendation: Perform a risk assessment to identify the various types of catheters and fittings in use, the possibility for misconnections, the potential severity of misconnections, and process changes that need to be made. Always trace the port and tubing back to its insertion site, and never attempt to force a connection that does not fit easily and securely into an access port. For additional recommendations to avoid catheter/tubing misconnections, The International Organization for Standardization (ISO) has been working on a standard that will make various healthcare catheter fittings and associated tubing sets or syringes incompatible with one another.

Post-production IV admixture checks less than ideal   (13)
Problem: Two fatalities occurred due to IV admixture errors that were not detected during the checking process. Checks performed after manual IV admixture preparation often involve the “syringe pullback” method, which is less than ideal. This type of error-prone check is based on the preparer’s memory of how much drug was added to the bag and proper placement of the syringe next to the used product in crowded spaces.
Recommendation: Utilize commercially available or outsourced premixed products whenever possible. When pharmacy admixture is required, products with a high-alert medication should employ an independent double-check of the vials, prepared syringes, and container labels prior to adding it to the solution. IV robotic preparation systems and commercially available workflow management systems also can decrease error potential.

Air embolism risk with pressurized sprayers   (15)
Problem: Although rare, serious and fatal (one death of a 22-year-old) air or gas embolisms have occurred during or immediately after application of fibrin sealants using air- or gas-pressurized sprayers. In some cases, the devices were used at a higher than recommended pressure or at a distance too close to the surface of the bleeding site.
Reccomendation: Educate surgical staff about this risk and proper use of the product. Use the applicator, spray set, and pressure control device or regulator as noted in the labeling. Use an air- or gas-pressure setting within the range recommended by the manufacturer. Ensure that the distance between the spray head and the tissue is at or above the minimum recommended by the manufacturer.

Utilize affirmative warning statements instead of negative warning statements (16)
Problem: Warning statements can be overlooked or misread depending on how they are presented. Negative and passive words in warning statements require more effort to interpret correctly. Thus, a healthcare provider under stress may fail to process the negative parts of the warning—such as “Do Not”—and misinterpret the warning as an affirmative action.
Recommendation:  Utilize affirmative warning statements (e.g., “IM use only” instead of “Not for IV use”) in an active voice to facilitate comprehension and compliance. Use a signal word: Danger for immediate, potentially deadly hazards; Warning for unsafe practices that may cause injury; Caution for hazards that can cause minor injury. The warning that follows should be explicit. 

Preparation of liquid niMODipine (16)
 If niMODipine must be administered through a feeding tube, FDA recommends puncturing the capsule with an 18 gauge needle, extracting the liquid contents with a parenteral syringe labeled “Not for IV Use.” However, this may result in accidental IV administration, particularly if only the “…IV Use” portion of the label is read. 
Recommendation: Liquid niMODipine should be prepared ONLY in the pharmacy and be dispensed ONLY in an oral syringe labeled “WARNING: For Oral Use Only.” Outsourcing the preparation of liquid niMODipine from a reliable compounding pharmacy is also an option.

v Confusion between American Regent’s vasopressin and atropine sulfate injections (17)
The 1 mL vials of American Regent’s vasopressin injection (20 units/mL) and atropine sulfate injection (0.4 mg/mL) look very similar because the font style and color used on the labels and caps are nearly identical.
Recommendation: Purchase one of the products from a different manufacturer to help distinguish the two. At a minimum, the products should be stored in separate locations whenever possible.

Do not add drugs to hanging IV bags (17)
 Adding a drug to a hanging IV bag poses many risks, including: infection control; drug incompatibilities; inadequate mixing to gain uniform concentration of the drug in solution; drug pooling at the spiked end of the bag or bottle, putting patients at risk of a potential overdose; label inaccuracies related to the actual concentration of the drug that is in the solution.
Recommendation:  Create and enforce a policy prohibiting the addition of medications to hanging parenteral nutrition solutions or IV solutions of any type.

American Regent caffeine and sodium benzoate injection dose confusion   (13)
A physician ordered caffeine 500 mg IV, intending for the patient to receive 500 mg of caffeine and sodium benzoate, not 500 mg of the caffeine moeity. The nurse based the dose on the caffeine component, which is prominent on the label and states that each vial contains 125 mg/mL of the caffeine moiety (250 mg caffeine total). The nurse used four vials to prepare the dose, so the patient actually received 1 gram of caffeine and sodium benzoate instead of the intended 500 mg.
Recommendation:  Alert staff that dosing confusion has been linked to the label of the recently revised American Regent product. Prescribers should specify whether the dose is based on the combination of components or just the dose of the caffeine. If not, clarify the order.

v Height and weight mix-up with electronic prescribing (17)
 While using an electronic prescribing system, a physician ordered 9 mg/kg of panitumumab (VECTIBIX) IV every 3 weeks for an adult patient. The physician inadvertently entered the patient’s height (cm) as the weight, and the weight (kg) as the height. The patient received 650 mg more panitumumab than intended.
Recommendation:  When possible, set protocol-based maximum doses in prescribing and pharmacy computer systems that require a reason for overriding an alert. Monitor the electronic alert system to minimize the number of low-priority alerts, and test for inclusion of high-priority alerts. Form an interdisciplinary team to identify how existing double-checks are being conducted.

Methylene blue overdose risk (13, 18)
Methylene blue is used as an antidote for drug-induced methemoglobinemia. Accidental overdoses of methylene blue occur occasionally; the patient could turn blue, which can be mistaken for cyanosis. Dosing errors are possible if the mg dose is accidentally prescribed as mL, or if the computer system lists the dose of methylene blue in mL.
Recommendation:  Ensure your computer system does not default to mL dosing for methylene blue. Educate prescribers to only order the medication in mg. Consider adding a maximum weight-based dose of 2.5 mg/kg to your pharmacy computer system for methylene blue to further protect against accidental overdoses.

Sound-alike names: FLUoxetine and PARoxetine, XANAX (ALPRAZolam) and FANAPT (iloperidone) (15)
 An 8-year-old child with anxiety and depression incorrectly received PARoxetine 10 mg instead of FLUoxetine 10 mg when a telephoned prescription was misheard. A nurse misheard the order for the new antipsychotic Fanapt as Xanax, which are both available as 1 and 2 mg oral tablets; it is likely that confirmation bias (hearing the familiar drug name) contributed to the mix-up.
Recommendation:  Use both the brand and generic names when prescribing look-alike/sound-alike drugs. Names on your look- and sound-alike list should be spelled back to the prescriber during read-back of a telephone or oral order. Ensure that a process exists to educate professional staff about new medications before they are added to the formulary and prescribed.

DORIBAX (doripenem) and ZOVIRAX (acyclovir) name confusion (19)
A unit secretary incorrectly interpreted a handwritten physician order for Doribax and entered Zovirax 500 mg IV q8h. Although the dose appeared to be appropriate for Zovirax, the order was written by a pulmonologist, which seemed unusual and prompted a pharmacist to clarify and correct the order transcription.
Recommendation:  Due to confirmation bias and frequent interruptions, weigh the risk of unit secretaries entering medication orders. Also, due to potential carbapenem resistance, limit the prescribing of Doribax to infectious disease physicians. Educate staff about the confusion between these two drug names.

“Biweekly,” “BIW,” and “bimonthly” confusion   (13)
The word biweekly usually means once every 2 weeks, but it can also mean twice-a-week. The word bimonthly usually means once every 2 months; however, it can also indicate twice a month. An order written for chlorambucil to be given “BIW” (intended meaning: biweekly or twice-a-week) was misinterpreted as “twice daily.”
Recommendation: Avoid “biweekly” (including the abbreviation BIW) and bimonthly when ordering medications. Instead, use terms such as “twice-a-week,” “every other week” (or “every 2 weeks”), or “every other month” (or “alternate months”)


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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