ISMP Quarterly Action
Agenda - January-March 2003
From the April 4, 2003 issue
One of the most important ways to prevent medication
errors is to seek and use knowledge proactively from other
organizations that already have 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
2002. 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. Many product-related
problems can be visualized in the ISMP Medication Safety Alert!
section of our website. The American Society of Healthcare
Risk Management (ASHRM) routinely provides the ISMP Quarterly
Action Agenda to all its members. Continuing education credit
related to this issue of the newsletter is available for pharmacists
and nurses (see www.ismp.org for details).
I. Drug Information
.II. Communication of Medication Orders
- Avoid IV infusions of plain sterile water for injection
(2, 5, 6)
Problem: Instances of prescribing and administering
sterile water for injection (prescribed as plain water
or free water) intravenously to treat hypernatremia
in patients with hyperglycemia or CHF led to several serious
errors and one patients death from hemolysis due to
the solutions hypotonicity.
Recommendation: Alert staff to the hazard
of infusing sterile water for injection intravenously. Develop
protocols for treating hypernatremia in patients with comorbid
conditions such as hyperglycemia or CHF. Store large volume
parenteral containers of sterile water in the pharmacy only.
Do not allow sterile water to appear as a choice on prescriber
order entry systems. Flash the warning Use Only as
a Diluent on pharmacy computer screens when sterile
water is entered.
- VZIG (varicella-zoster immune globulin) and VARIVAX
(varicella virus vaccine) confusion (2)
Problem: Confusion between these
products has led to administration of Varivax to pregnant
women, which is specifically contraindicated in pregnancy.
Recommendation: Alert clinicians to the differences
in these products and use computer alerts and warning labels
to remind staff. Store the products separately and obtain
a pregnancy history as appropriate to help prevent fetal
exposure to the vaccine.
- Use short-acting insulin with LANTUS (insulin glargine)
Problem: Lantus provides a basal insulin level
over 24 hours. To ensure proper postprandial blood glucose
control, short-acting insulin also should be prescribed
to control hyperglycemia after meals. Yet Lantus is often
prescribed without such insulin coverage or in combination
with other agents that have inappropriate pharmacokinetic
profiles for mealtime coverage.
Recommendation: Use short-acting insulin to control
postprandial glucose levels to within specified guidelines
as established by the International Diabetes Federation
and the American College of Endocrinology.
- New formulation for KAOPECTATE (5)
Problem: Kaopectate has been reformulated to
contain bismuth subsalicylate. Because the change is not
readily apparent on the label, the product may be used by
patients for whom it now is contraindicated (e.g., salicylate
allergies, children recovering from chicken pox or the flu).
The new formulation also causes dark-colored stools, which
could be misdiagnosed as a symptom of gastrointestinal bleeding.
Recommendation: Use auxiliary labels and computer
alerts to advise clinicians of the formulation change and
contraindications for use. Also, alert patients to the change
if the product is likely to be used after discharge
III. Drug Labeling, Packaging, and Nomenclature
- Use mL, not cc (5)
Problem: An order for heparin 25 cc
per hour (intended dose of 1,000 units/hour) was misinterpreted
as 25 units per hour when the handwritten cc
looked more like a u.
Recommendation: Use mL not cc
when expressing volume in handwritten, preprinted, and electronic
- Several sources of error when prescribing levothyroxine
Problem: Misplaced decimal points, mathematical
errors when converting milligrams to micrograms, and confusion
about IV to oral dose conversion are commonly reported problems
that have led to serious errors with levothyroxine products.
Recommendation: Encourage prescribers to order levothyroxine
in micrograms to avoid using decimal points. Build computer
alerts for doses greater than 200 mcg. With the products
long half-life, patients do not need to be switched from
oral to IV levothyroxine during short periods of NPO status.
- Standards needed for communication of electronic
Problem: As with handwritten orders, electronic
prescriptions can lead to miscommunication if dangerous
abbreviations and dose expressions are used. Other conditions
unique to electronic communication of medication orders
also pose a risk (e.g., the letter l looks like
the number 1). Standards for communication of
electronic orders are needed to avoid these risks.
Recommendation: With input from our subscribers,
ISMP has developed and published draft standards to begin
the process of establishing national standards for electronic
communication. Clinicians are encouraged to provide comments.
Similarly, pharmacists should take a lead role in developing
internal standards for electronic (or print) communication
of medication orders, working with other departments, including
IV. Issues Related to Drug Delivery Devices, Patient Education,
and Human Factors
- Packaging similarities with ketorolac and atracurium
Problem: Mix-ups are possible between 10 mL vials
of Baxters atracurium and Bedfords ketorolac
because both have similar lavender colors on the labels
and gray snap-off caps.
Recommendation: Sequester neuromuscular blocking
agents from other medications and dispense them with auxiliary
warning labels noting that the medication is a paralyzing
agent. Carry only 30 mg or 60 mg vials of ketorolac, since
doses should not exceed 60 mg (2 mL).
- INFANTS TYLENOL (acetaminophen) CONCENTRATED
Problem: The concentration is listed on the outside
box, but not on the bottle. If the carton is discarded,
there is no way to determine the milligram dose.
Recommendation: The manufacturer has been notified.
A change will be made temporarily and new labels will be
available next year. In the meantime, alert parents to the
problem and place auxiliary labels listing the concentration
on the bottles before dispensing the product in inpatient
- Fatal reports of intrathecal vincristine continue
Problem: Another fatality occurred after vincristine
was dispensed without a warning label on the syringe and
outer wrapper (per USP standards), and the medication was
administered intrathecally, along with the prescribed intrathecal
chemotherapy, instead of intravenously.
Recommendation: Consider dispensing vincristine in
a small mini-bag (with USP-required warning labels) to differentiate
it from intrathecal medications.
Administer intrathecal medications in a designated location
and have pharmacy deliver them to the specified location
immediately before use. Never dispense or deliver intrathecal
and IV medications together. Require at least two clinicians
to independently verify intrathecal medications before administration.
- Confusion with ABILIFY (aripiprazole) and proton
pump inhibitors (5)
Problem: The prazole ending in aripiprazole
could lead to misclassifying this antipsychotic medication
as a proton pump inhibitor.
Recommendation: As new drug products are released,
familiarize yourself with the indications, doses, and adverse
effects before ordering, dispensing, or administering these
- Confusion between ZETIA (ezetimibe) and ZESTRIL
Problem: Due to name and dose similarities, coupled
with a poorly handwritten prescription, a pharmacist erroneously
dispensed Zestril instead of Zetia.
Recommendation: Specify the medications indication
on prescriptions and ensure that patients know its purpose.
Encourage patients never to leave the pharmacy without verifying
with the pharmacist that the prescription matches what their
doctor told them.
- New color-coding for 25 gauge safety needles may
lead to errors (5)
Problem: Globally distributed 25 gauge safety
needles must conform to new international standards requiring
orange color-coding. Nurses have long associated orange
color-coding with insulin syringes. Recently, a nurse accidentally
used a tuberculin (TB) syringe (with an attached 25 gauge
needle) that had an orange plunger tip to draw up a dose
of insulin. The patient received 50 units of insulin, not
5 units as prescribed, because the .5 mL mark
(absent the leading zero) on the syringe was misread as
the 5 unit mark.
Recommendation: Alert nurses that the orange color-coding
is no longer used exclusively for insulin syringes. Some
hospitals are using 26 gauge (brown) or 27 gauge (gray)
needles on TB syringes to avoid mix-ups.
- Failure to remove unneeded parenteral lines leads
to errors (2)
Problem: Parenteral lines left in place when no longer
needed led to two serious errors. In one case, an infants
mother injected AUGMENTIN (amoxicillin/ clavulanate) oral
suspension, drawn into a parenteral syringe, into the childs
heparin lock (used previously for IV antibiotics), causing
respiratory arrest. In another case, a nurse administered
25 mg of meperidine via an arterial line that was left in
place inadvertently after transfer out of ICU.
Recommendation: Remove all unnecessary parenteral
access lines as soon as possible. Stock and use oral syringes
for all oral liquid medications. Ensure clear labeling of
all access lines that must be maintained, and trace each
line back to its insertion site to verify the route of administration.
- Enteral feeding given IV (6)
Problem: Because enteral feeding bags can be
spiked with an IV administration set, several cases of administering
enteral feedings by the IV route
have been reported. In many cases, the patient was supposed
to receive three-in-one TPN solution, which has a similar
appearance to enteral feeding.
Recommendation: Use large, bold auxiliary labels
on enteral feedings that state WARNING! For enteral
use only - NOT for IV use. Also, use a rubber band
to attach an appropriate enteral administration set to all
enteral feedings before distribution to (or storage in)
patient care units to ensure ready availability. Manufacturers
have been asked to redesign the enteral bags so that they
cannot attach to IV administration sets.
- Translation inaccuracies (4)
Problem: Studies show that interpretation errors
occur about 31 times during each encounter when translators
are used to communicate medical information to patients
who speak a language other than English. About 63% of these
translation inaccuracies could have potential clinical consequences.
Recommendation: Ensure proper training and screening
of translators. Schedule non-English speaking patients to
come in on days when translators are available. With proper
training, students majoring in foreign languages may be
a good source for translation services.
- Double checks are worth your time (5)
Double checks carried out by people fail at times. But,
statistically speaking, research shows that double checks
are worth your time, catching 95% of errors at each verification
point. To get this type of accuracy, checks need to be independently
performed, and staff need to be trained on the proper technique.
The ISMP Quarterly Action Agenda is now
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