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ISMP Quarterly Action Agenda: October - December, 2001


From the January 23, 2002 issue

One of the most important ways to prevent medication errors is to proactively seek and use knowledge from other organizations that have already experienced similar problems. To promote such a process, administrative staff and an interdisciplinary committee at each practice site should review the following material to prompt discussion and stimulate action to reduce the risk of errors. The following selected items appeared in the ISMP Medication Safety Alert! between October - December 2001. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information as desired. Agenda items are posted on our web site and many product-related problems can be visualized in the ISMP Medication Safety Alert! section. ACPE credit is available for pharmacists (see www.ismp.org for details). The American Society of Health Care Risk Management (ASHRM) routinely provides the ISMP Quarterly Action Agenda to all its members.

I. Look-alike/sound-alike drug names and other product-related issues
  • ZYRTEC (cetirizine) and ZYPREXA (olanzapine) (22)
    Problem: ISMP has received a number of reports about mix-ups between the antihistamine, Zyrtec (cetirizine), and Zyprexa (olanzapine), an antipsychotic. Both drugs are available in 5 mg and 10 mg tablet strengths.
    Recommendation: Alert staff to the possibility of mix-ups. Prescribers should include the purpose of the medication on prescriptions. Store these drugs separately and place reminders on containers and in computer systems. Outpatient pharmacists should verify NDC numbers.
  • ADD-Vantage vials from Abbott partner companies (23)
    Problem: A patient developed shortness of breath, bronchospasm, and chest tightness after receiving ampicillin. At first, this was thought to be a penicillin reaction, but the patient gave a history of being allergic to latex. Although the label on Abbott ADD-Vantage system minibags are prominently marked "latex free," and all Abbott ADD-Vantage vials (except tobramycin) are latex-free, some ADD-Vantage vials from Abbott partner companies may have latex in their stoppers.
    Recommendation: If using ADD-Vantage drug containers from Abbott partner companies, contact the companies for updated information concerning latex-free status for the specific product.
  • Confusing dosage formulations (24)
    Problem: Confusion is likely when a medication is available in oral dosage forms with different release rates. METADATE ER and METADATE CD both contain methylphenidate hydrochloride extended-release, but they're not substitutable. The CD product is a once-a-day capsule with biphasic release. The ER product is a tablet given two to three times a day. Confusion also can be expected between the new methylphenidate product, RITALIN LA, and previously available RITALIN SR, as well as between DEPAKOTE ER (divalproex sodium extended release) and DEPAKOTE (divalproex sodium delayed release).
    Recommendation: Carefully select new formulary medications with the knowledge that confusion between different formulations and suffixes is likely. Verify new prescriptions for any of these medications. Build alerts into computer systems and mark drug containers to warn staff about the differences. Design mnemonics to separate the different formulations on the computer screen. Alert patients to possible confusion so they can help identify an error before taking the medication.
  • PEG-INTRON (peginterferon alfa-2b) (24)
    Problem: Errors have been reported with PEG-Intron (peginterferon alfa-2b), which is used to treat chronic hepatitis C. The misleading dilution and concentration expressions on the label have led to underdosing. Vial sizes are currently labeled as 100 mcg/mL, 160 mcg/mL, 240 mcg/mL, and 300 mcg/mL. However, each strength must be diluted in 0.7 mL and, although the concentration expression is correct on a per mL basis, each vial actually contains enough drug to prepare 70 mcg/0.7 mL, 112 mcg/0.7 mL, 168 mcg/0.7 mL and 210 mcg/0.7 mL, respectively. Also, from a reconstituted vial, 0.5 mL or less represents the typical intended dose. The remaining volume is provided as overfill.
    Recommendation: New labeling, clearly stating the dose on a 0.5 mL basis, has been approved and is being introduced into production. For now, alert staff to possible dose confusion by using computer alerts or auxiliary warning labels.

II. Dangerous abbreviations and other unsafe ways of communicating orders

  • Indicate medication's purpose on prescriptions (20)
    Problem: An elderly woman was prescribed amitriptyline to treat neurogenic pain syndrome, but her physician didn't tell her why it was being prescribed or write the reason for the medication on the prescription. The pharmacist told the patient that the drug was being prescribed for depression. The patient refused the medication and accused her physician of believing her pain was all in her head.
    Recommendation: Along with appropriate explanations and instructions to the patient, prescribers should indicate the purpose of each medication on prescriptions, especially for "off-label" uses and look-alike/sound-alike drug name pairs known to be problematic.
  • Heparin products (21)
    Problem: We continue to learn of fatalities from concomitant use of low molecular weight heparin (LMWH) and unfractionated heparin and other anticoagulants. A patient died after receiving LOVENOX (enoxaparin) 66 mg subcutaneously, three times in 20 hours, along with heparin 10,000 units and PLAVIX (clopidogrel) 300 mg.
    Recommendation: Be sure that computer alerts for duplicate therapy are fully functional for all heparin products. Use protocols, guidelines and standard order forms to assure that current and recent drug therapy is considered before ordering, dispensing, and administering heparin products. Keep in mind that communication of drug therapy administered in the emergency department or cardiac catheterization lab may not be standardized and may not appear on the patient's drug therapy profile, especially if it was a one-time dose.
  • U-100 insulin syringes are not meant for measurement of U-500 insulin (21)
    Problem: An endocrinologist wrote an order for "25 units of U-500 insulin" to be given in the morning. However, in reality, he wanted the patient to receive 125 units. Since each mL of U-500 insulin contains five-fold more insulin than U-100, he was actually citing the "25 units" marking on the U-100 insulin syringe scale.
    Recommendation: Since U-500 syringes are not available, use a tuberculin syringe to measure U-500 insulin dose. Order the drug in both units and volume (e.g., 200 units, 0.4 mL). Avoid using U-500 insulin for doses below 100 units. Staff preparing U-500 insulin doses should request an independent check by a second health professional. Keep in mind that patients measuring U-500 doses with a U-100 syringe at home may likewise mislead staff by citing the U-100 syringe scale reading instead of the actual U-500 insulin dose.
III. Other discussion items
  • Failure Mode and Effects Analysis can help guide error prevention efforts (21)
    JC's new patient safety standards require hospitals to engage in proactive risk management activities, including failure mode and effects analysis (FMEA). Although industries outside of medicine have developed elaborate FMEA scoring systems to rank items for action, the simplified FMEA process described in our October 17, 2001, issue can be an efficient proactive risk management tool, especially when organizations consider what already is known about error potential from past experiences or information available in the media such as the ISMP Medication Safety Alert!.
  • Health literacy (22)
    Poor "health literacy" is not an obvious problem and it's more prevalent than many assume. People who cannot read or understand health information are ashamed and often hide the problem. Researchers report poor reading skills in some of the most poised and articulate patients. Assume that everyone has a "health literacy" problem. People at all literacy levels prefer simple, straightforward instructions and written materials.
  • Patients taking their own medications when hospitalized (23)
    Hospitalized patients have been known to take their own medications without telling their healthcare providers. Ask hospitalized patients if they have any of their medications with them. If yes, send the medications home with the family after taking an inventory. Instruct patients not to take any products unless a nurse or doctor specifically instructs them to do so. Describe potential problems with self-medication when hospitalized and provide this information in other instructional materials.
  • Connection ports (24)
    As a consequence of compatible Luer connections, lack of knowledge of tracheostomy tube components, and an unsecured triple lumen catheter, a patient died from asphyxiation after an IV line was attached and fluid infused into the tracheostomy cuff pilot line instead of the IV catheter. Hospitals should have a policy whereby error potential of all new devices is identified through failure mode and effects analysis, staff are trained before using new devices, and all lines are traced from the source when attaching tubes or instilling products.
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