1997 Cheers and Jeers
From the January 14, 1998 issue
In 1997, there were some great strides forward as well as
a few steps back in medication error prevention. We felt that
recognition was due for both, and so, without further ado,
here are ISMP's top CHEERS and JEERS:
CHEERS to the pharmaceutical companies responsive
to product labeling, packaging, nomenclature and design problems.
Marsam redesigned the label for cefazolin 10 g bulk
vials to distinguish it more clearly from the 1 g single-use
vial. Amgen updated the epoetin alfa label to include
a warning about increased mortality when aggressive dosing
is used in CHF or angina patients undergoing hemodialysis.
Baxa Corporation redesigned the tips of the Exacta-Med
oral syringes to minimize the potential for use with needleless
IV systems. Bristol-Myers Squibb repackaged Platinol®
(cisplatin) to stem errors from mix-ups with Paraplatin®
(carboplatin). A special thumbs up to pharmaceutical
companies that now obtain practitioner input on potential
safety problems with labeling, packaging and nomenclature
prior to product launch.
CHEERS to FDA for requiring products containing
30 mg or more of iron per unit to be packaged as individual
doses; the new packaging will decrease the number of doses
a child could readily ingest. But JEERS to FDA
and manufacturers for allowing the product's identity on each
UD package to be replaced by iron-related warnings. This could
slow ER personnel who need to identify what product was taken
in accidental poisoning situations, and it requires pharmacy
to repackage the product for use in institutions.
JEERS to those companies that ignore serious medication
safety concerns. Confusion about Cerebyx®
(fosphenytoin) continues more than a year after product launch
with no indication from Parke-Davis that it plans to improve
the flawed prescribing system. Pharmaceutical companies confuse
both practitioners and consumers by extending product line
names to new products that do not contain the same drugs.
JEERS to healthcare plans that place profit over patient
safety. As a cost savings measure, one managed care plan covers
Pepcid AC 10 mg but not the other strengths, forcing patients
on higher doses to take multiple tablets. Washington State's
legislature did the same with other drugs, increasing
the risk of medication errors, such as underdosing, overdosing
or decreased compliance, which may, ironically, increase costs.
CHEERS for innovations that help to prevent errors,
such as bar code technology, direct physician computer order
entry, and Triple i prescription blanks that use anatomical
icons to indicate the drug's purpose. These products can reduce
medication errors by linking the drug prescribed with its
therapeutic use or with the proper patient.
JEERS to the Denver and Toronto criminal
justice systems. Three Colorado nurses were indicted in a
baby's death because long-acting penicillin was given IV instead
of IM after the nurses misinterpreted information on the route
of administration. In Toronto, a nurse was indicted after
accidentally injecting potassium chloride concentrate instead
of furosemide, resulting in the death of a patient. CHEERS
to the medical professionals who refused to provide expert
testimony against a nurse in another Colorado case in which
a patient died. Largely for that reason, the District Attorney
did not pursue criminal charges against the nurse who crushed
oral medications and administered them IV because the patient
refused to take the medications.
CHEERS to companies that provide clear and accurate
resource materials and advertisements. While many companies
continue to use dangerous abbreviations in advertisements
and labeling, Bristol-Myers Squibb voluntarily changed
"u" in its Blenoxane®
ad to "units" to prevent any possible errors. Due to concern
for accuracy, the new Journal of Oncology Nursing
requires authors to submit with their manuscript copies of
primary dosing references and cited references.
CHEERS to Bridge Medical, Inc., for sponsoring
"Beyond Blame," a video that premiered at a town hall meeting
on medication errors hosted by Dr. C. Everett Koop and attended
by 2000 pharmacists during the ASHP MidYear Clinical Meeting
in Atlanta. The video and town hall meeting focused on the
impact of errors on healthcare professionals who commit them,
emphasizing that blaming practitioners will not prevent future
errors. By the same token, JEERS to institutions that
use a punitive approach to medication errors, which only discourages
reporting. Also, JEERS to institutions that still supply
potassium chloride concentrate injection to patient care units
instead of cost-effective, safer alternatives even though
we've reported numerous patient deaths caused by this practice.
Our loudest CHEERS are for practitioners who report
adverse drug events to their institutions, the USP-ISMP Medication
Errors Reporting Program and the FDA MEDWATCH program. By
reviewing and learning about external errors, you can work
to prevent the same errors from happening in your organization.