ISMP Quarterly Action
Agenda: January - March, 2000
From the April 5, 2000 issue
One of the most important ways to prevent adverse drug events
is for organizations to proactively seek and use knowledge
learned from other organizations that have already experienced
problems. To make a significant impact on error prevention
efforts, administrative staff and an interdisciplinary committee
at your practice site should review the following agenda to
prompt discussion, and then take the necessary action to minimize
adverse drug events in your facility. The following selected
items appeared in the ISMP Medication Safety Alert! between
January and March, 2000. Each item includes a description
of the problem, recommendations for safe medication practices,
and the issue number (in parentheses) to locate additional
information. A list of agenda items is also posted on our
web site (www.ismp.org). In many cases, pictures of product-related
problems can be seen in the ISMP Medication Safety Alert!
section of our web site. The American Society of Health Care
Risk Management (ASHRM) provides the ISMP Quarterly Action
Agenda to all its members.
I. Look-alike/sound-alike drug names, ambiguous or
look-alike labeling and packaging
II. Misinterpretation or miscommunication of drug orders
- SUFENTA (sufentanil) and SUBLIMAZE
Problem: Confusion between Sufenta and
Sublimaze has resulted in multiple episodes of respiratory
arrest. The risk of confusion is high because both drugs are
potent analgesic/anesthetic products with very similar generic
names. Selecting the wrong drug via the computer mneumonic
"su" has also resulted in errors.
Recommendation: Consider removing one
of these drugs from the formulary. If both drugs remain in
use, educate staff about the different potency of these products
and include visual reminders wherever they are stored. Configure
computer screens (including those on automated dispensing
cabinets) to prevent the two drugs from appearing consecutively
on the same screen.
- Confusion with caffeine citrate labeling
Problem: Caffeine citrate (Cafcit), recently
marketed by Roxane Laboratories, is labeled 20 mg/mL but practitioners
can easily miss that the 3 mL vial actually contains 60 mg
since the volume is not connected to the concentration statement
on the package label. Also, the product is often dosed in
terms of its base (10 mg/mL) and not the salt (20 mg/mL) although
the package label highlights the salt.
Recommendation: Prior to dispensing,
pharmacists should apply auxiliary labels or circle the total
volume to clarify the total amount in the vial. Develop a
protocol to clearly delineate how the drug is to be dosed.
- Novaplus packaging (4, 5)
Problem: Similarities exist between various
parenteral chemotherapeutic agents packaged under the Novaplus
brand. Several drugs have identical blue and white color schemes
and are available in the same size cartons and vials. Vials
of diltiazem injection and atracurium injection also look
alike with a blue and yellow color scheme. A mix-up could
Recommendation: Novation has agreed to
look into the matter. For now, do not store products together
on shelves, in bins, or in refrigerators. Prior to dispensing,
pharmacists should enhance each package with auxiliary labels
or circle the drug name to call attention to the product identity.
- Unusual instructions for administering
SPORANOX (itraconazole) IV (5)
Problem: The recommended dose of Sporanox
is 200 mg, but each 250 mg (25 mL) ampul must be added to
a 50 mL bag of 0.9% sodium chloride injection for product
solubility. Only 60 mL of the resulting 75 mL solution is
needed to administer 200 mg. Unless the infusion is stopped
manually after 60 mL has been infused, or a volume control
set or volume-limiting infusion pump is used, 250 mg will
be administered in error.
Recommendation: The manufacturer modified
its preparation instructions and now recommends removing the
excess 15 mL before the container is used for infusion (leaving
200 mg/60 mL).
- Abbott CARPUJECT metoclopramide
injection and metoprolol confusion (5)
Problem: Carpuject boxes of metoclopramide
(10 mg per 2 mL) and metoprolol (5 mg/5 mL) look very similar.
The drug names share the first four letters (M-E-T-O) and
both packages have green and blue "rocket stripes" on the
bottom right corner of the box.
Recommendation: Use a marker to circle
or "yellow out" portions of the label to help differentiate
these items. Otherwise, purchase one item from a different
manufacturer until Abbott enhances the packaging.
- BENTYL (dicyclomine) Injection label
confusing practitioners for the past year (6)
Problem: Bentyl 2 mL ampuls list the
10 mg/mL drug concentration but not the volume or the total
content of 20 mg/2 mL. This has lead to confusion and numerous
Recommendation: If Bentyl ampuls are
present in your practice site, add a cautionary note to each
ampul to remind users of the actual contents (20 mg/2 mL).
New ampuls with enhanced labeling will begin shipment in late
April or May, 2000
- Confusion when using prescription labels
for non-prescription products (1)
Problem: A bottle of insecticide with
a prescription label was confused with an oral liquid medication.
Recommendation:When supplying units with
labels, do not use pharmacy prescription labels (labels imprinted
with the pharmacy's name, address, etc.). Only blank labels
or other labels that cannot be confused with prescription
labels should be made available outside the pharmacy.
III. Discussion Items
- PROCAN SR (procainamide hydrochloride
sustained release) dispensed for PROCANBID (procainamide
hydrochloride extended release) (5)
Problem: Procan SR, dosed every 6 hours,
was recently withdrawn from the market, but the sustained
release form remains available generically. Confusion between
the sustained release product and the extended release product,
Procanbid, given no more frequently than every 12 hours, has
resulted in dispensing errors.
Recommendation: The two forms of procainamide
are not substitutable with each other. Decide which form should
remain available on formulary and consider eliminating the
other item from inventories.
- Probenecid (BENEMID) mistaken for
PROCANBID (procainamide hydrochloride extended release)
Problem: Procanbid 500 mg twice a day
was dispensed after misreading a poorly handwritten order
for probenecid 500 mg bid. In another case, a drug cart was
misfilled with probenecid 500 mg when Procanbid 500 mg was
misread on a computer printout.
Recommendation: Use a computerized alert
or auxiliary container labels to alert staff to potential
mix-ups. Store drug containers apart and design computer mnemonics
to prevent the drugs from appearing together on the computer
screen. Know the patient's diagnosis to determine if he needs
an antiarryhthmic, uricosuric, or a penicillin adjuvant.
- After sublingual use of nifedipine rejected
by experts, intended sublingual dose accidentally administered
IV (1, 3)
Problem: After using a parenteral syringe
to withdraw a nifedipine capsule's liquid content, a patient
received the intended sublingual dose as an IV injection.
FDA advisory panel and other experts have rejected sublingual
use of this product.
Recommendation: Prohibit the use of nifedipine
by the sublingual route and use suitable alternatives to treat
hypertensive emergencies. Use specially designed oral syringes
that do not connect to IV tubing when preparing any oral liquid
medication for inpatients.
- Computerized physician order entry
(CPOE) will soon be required if caring for patients from
some Fortune 500 companies (1)
CPOE is one of the safety standards being initiated
by the Leapfrog Group, a think tank that represents large
employer organizations and the Business Roundtable, whose
members are CEOs from Fortune 500 companies. To meet the standard,
hospitals will have to demonstrate that its software intercepts
a minimum percentage of common, serious prescribing errors,
using a testing protocol being developed by ISMP. An implementation
date will soon be announced for the CPOE purchasing standard.
- IOM report notes that oversight of the
hospital's medication system might be placed under a single
The IOM report states that individuals or departments
"own" a piece of the medication system, but as a rule, no
one manages the system as a whole. Thus, the report suggests
that a dedicated clinician (e.g., pharmacist with 50% of his
or her time devoted to this role) provide oversight of the
hospital's medication system and the multidisciplinary medication
improvement team. Gain leadership backing and financial support
for such a position. With budget preparation around the corner
for many, now may be a good time to begin discussions on this
- Full and timely disclosure of errors
to patients is the best policy (4)
The Veterans Affairs (VA) Medical Center in
Lexington, Kentucky, recently reported encouraging data on
a courageous and ethical institutional policy to disclose
errors to patients and to equitably compensate patients/families
for their actual loss. When compared to other VA medical centers,
the Lexington facility is in the top quartile for number of
claims filed, but at the bottom quartile for payments. Full
disclosure of errors and just compensation for injuries seems
to be a solution that is both ethical and cost effective.
It restores organizations and practitioners to a patient advocacy
role, putting the patient's interests first, while potentially
minimizing the organization's financial impact.
- A multidisciplinary team is essential
to medication error reduction efforts (5)
The first priority for successful error reduction
efforts lies in establishing a multidisciplinary team. The
multidisciplinary nature of the team significantly increases
the success because effective results depend on looking at
the complex medication use process as a whole and understanding
how major functions interact through varied perspectives and
disciplines. Equally important, leadership must demonstrate
their commitment to medication safety by providing these teams
with the necessary time and resources to discharge their responsibility.