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ISMP Quarterly Action Agenda - January-March 2004


From the April 22, 2004 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 agenda items have been prepared for your administrative staff and an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. These agenda topics appeared in the ISMP Medication Safety Alert! between January and March 2004. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number (in parentheses) to locate additional information as desired. Many product-related problems may also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses. Click here for details.

I. Information about the patient or medication

  • Confusion with 2002 Broselow tape (4)

    Problem: Practitioners have reported confusion with the 2002 Broselow tape. For example, the tape lists IV push drug doses in mg or mEq, but uses volumetric measures (mL) for infusions.

    Recommendation: Establish a standardized approach to teach clinicians how to use the tape and assess preparedness by performing regular mock codes. Have nurses open code carts regularly to become familiar with the tape and cart contents. Ensure that the drug concentrations in a pediatric code cart correspond to the ones listed on the tape.

  • Caution needed with flammable products (5)

    Problem: Flammable medications have ignited accidentally when exposed to a heat source (even static discharge), yet manufacturer warnings on flammable products are poorly visible. A 6-year-old child's infected toe was treated with ethyl chloride spray before lancing and the entire area burst into flames when a nurse practitioner triggered a cautery device.

    Recommendation: Ensure that all healthcare workers are aware of the dangers of flammable products. Reevaluate the need for these products, as there may be safer alternatives, especially for local anesthetics. If flammable products are used, affix auxiliary labels to clearly alert staff to the danger.

II. Communication
  • Expressing large doses (5)

    Problem: Expression of doses such as 1,000,000, 100,000, and 1,000 can cause confusion and result in serious dosing errors, especially if commas are missing or misplaced (e.g., 1000000, 100000, 1000).

    Recommendation: Because words exhibit more distinguishable characters than numbers, use a combination of both numbers and words (e.g., 1 million, 100 thousand, 1 thousand) when expressing large doses. Avoid abbreviations, such as M for million and K for thousand, which can be ambiguous.

  • Tragic errors with concentrated morphine solutions (4)

    Problem: Concentrated forms of oral morphine solution have often been confused with the standard concentration, leading to serious errors. An elderly man died after receiving 100 mg of ROXANOL (concentrated morphine solution) instead of the prescribed 5 mg. Accidental selection of the wrong concentration, and prescribing/labeling the product by volume, not milligrams, contributes to these errors.

    Recommendation: Dispense concentrated oral morphine solutions only when ordered for a specific patient (not as unit stock). Affix an auxiliary label to concentrated solutions to avoid confusion with standard concentrations. Always prescribe or dispense liquid medications with the dose specified in milligrams. Educate staff about errors and develop guidelines for safe use.

  • Practitioners speak up about intimidating behavior (5, 6)

    Problem: In a recent ISMP survey with over 2,000 respondents, almost 90% reported that they have encountered intimidating behavior in the last year. Only 39% of respondents felt that their organizations had dealt effectively with these behaviors.

    Recommendation: Define intimidation and create a code of conduct that outlines unacceptable behaviors. Survey staff about intimidation and hold frank discussions about the survey results to open the dialog. Establish a standard assertive communication process for use among healthcare providers who must convey important information. Teach staff a conflict resolution process to ensure patient safety in the face of disagreements. Encourage confidential reporting of intimidating behavior and enforce zero tolerance.

III. Drug labeling, packaging, and nomenclature

  • BICILLIN C-R (penicillin G benzathine and penicillin G procaine) and BICILLIN L-A (penicillin G benzathine) (6)

    Problem: Over 300 patients at a clinic were treated for syphilis using Bicillin C-R (which is not effective for this indication) instead of Bicillin L-A. Similar product names, packages, and labeling contributed to the error.

    Recommendation: Prevent mix-ups by adding reminders in computer systems and on storage shelves/package labels, and reviewing the pharmacy processes for receipt and storage of inventory.

  • Avinza (morphine extended release) and Evista (raloxifene) (5)

    Problem: A handwritten order for Avinza 60 mg was misinterpreted as Evista. The error was discovered after the physician increased the Avinza dose to 90 mg when the patient's pain continued.

    Recommendation: Add an alert to the pharmacy computer system for this new look-alike name pair. Always match the patient's diagnosis to the prescribed medication before dispensing and administering a drug.

  • WELLBUTRIN (bupropion) XL and SR (1)

    Problem: A psychiatrist ordered Wellbutrin XL 300 mg. The pharmacist was not aware of the new formulation, so he misinterpreted the poorly written order and dispensed two Wellbutrin SR 150 mg tablets for each dose.

    Recommendation: Inform staff about the different Wellbutrin formulations and dosing schedules. Warnings on pharmacy computers and pop-up alerts can also minimize confusion.

  • Carpuject syringe mix-ups and potential for tampering (2)

    Problem: Since conversion to a needleless system, Abbott's Carpuject syringes all have a Luer tip with an identical green cap and look-alike labels. Numerous syringe mix-ups between potentially harmful products (e.g., ketorolac, heparin, digoxin, opiates) have been reported. Switching opiate syringes with other syringes (e.g., promethazine) for the purpose of diversion has also been reported, despite packaging in a tamper-resistant SLIM-PACK.

    Recommendation: The manufacturer is currently in the process of enhancing the labels on Carpuject syringes. Until then, consider using auxiliary labels to differentiate problem products. To minimize tampering, ask nurses to inspect the drug name on each syringe (not just the bottom or top of the sealed tubes) during narcotic counts. Assure that Carpujects are stored in their original carton in a way that label panels can easily be read.

  • DuoFit XYLOCAINE (lidocaine) ampuls (3)

    Problem: After a patient complained of burning during a potassium infusion, a physician wrote an order to add lidocaine to each 250 mL bag. The nursing supervisor retrieved what she thought were 1 mL ampuls of 1% Xylocaine (10 mg per ampul), but she actually picked up 10 mL Polyamp DuoFit Xylocaine ampuls (100 mg per ampul), in part related to poor visibility of the labels on these plastic ampuls. The patient received 500 mg of lidocaine.

    Recommendation: To improve label visibility, leave Polyamp DuoFit Xylocaine ampuls in their overwrap until needed. Reassess the need for storing 10 mL vials of lidocaine in night cabinets, as well as the risks and benefits of adding lidocaine to bags of potassium chloride. In cases where this is warranted, have the pharmacy (when available) prepare the solution.

  • Infliximab (REMICADE) and rituximab (RITUXAN) (3)

    Problem:
    An order for infliximab 500 mg IV every 6 weeks was misinterpreted and rituximab was actually dispensed and administered. Both drugs are monoclonal antibodies and doses could possibly overlap.

    Recommendation: Include both the brand and generic names for these products, along with the indication, on handwritten and pre-printed orders, and on pharmacy-applied labels. Require an independent double-check before dispensing and administering either product.
  • PROTONIX (pantoprazole) and protamine (6)

    Problem: Recently, two cases of confusion between Protonix and protamine were reported. Both errors were detected, so neither patient received the wrong medication. But considering the nature of the medications, serious harm could have resulted.

    Recommendation: Add a look- and sound-alike alert to the pharmacy computer system, and on automated dispensing cabinet screens if the products are stored there. Always match the patient's diagnosis to the medication before dispensing or administering medications.

  • HEMOCCULT Sensa (4.2% hydrogen peroxide, 80% denatured ethyl alcohol) and eye drops (4)

    Problem: The wife of a hospitalized patient accidentally administered Hemoccult Sensa into her husband's eyes. The bottle had been left at the bedside, and it looked similar to the patient's artificial tears solution.

    Recommendation: Never leave developer solutions in areas where they can be confused with ophthalmic products (including patient rooms, bathrooms, and medication storage areas). Secure these products in a soiled utility room and confirm the safe storage of developer solutions periodically.

IV. Drug distribution, pumps, and computers

  • Potassium chloride error harms child (6)

    Problem: A homecare pharmacy dispensed a syringe containing concentrated potassium chloride for a mother to add to her child's TPN after a prescribed increase in the potassium content. The mother confused the potassium syringe with a saline flush and administered it IV push. The child arrested and was resuscitated, but suffered residual harm.

    Recommendation: Send only a 2-3 day supply of TPN to homecare patients when therapy is initiated. Return the TPN and have pharmacy add the required electrolytes if changes are made in the prescription.

  • Errors during refill of implanted Medtronic pump (1, 6)

    Problem: FDA received reports of fatal overdoses caused by accidental intrathecal injections of concentrated morphine while refilling implanted Medtronic SynchroMed infusion pumps. The medication had been intended for the pump's reservoir. A template was available in a refill kit to locate the reservoir port, but a similarly packaged catheter access kit was used instead.

    Recommendation: If you use or plan to use these devices, conduct a failure mode and effects analysis to determine error potential. Create standardized order sets for refilling the pumps and include the applicable refill kit number. If possible, use devices with only a reservoir port, not a catheter access port. If pumps with catheter access ports are necessary, keep the catheter access kits separated from the refill kits.

  • Testing the computer on "live" patients (1)
    Problem: While testing a pharmacy computer system, an information technology staff member entered an amoxicillin order for a "live" patient with an amoxicillin allergy. The drug was dispensed and administered to the patient, who developed toxic epidermal necrolysis.

    Recommendation: Avoid granting access to live patient profiles to anyone other than pharmacy staff. Use only "test" patients when evaluating the pharmacy system or for demonstration purposes.


The ISMP Quarterly Action Agenda is now approved for Continuing Pharmaceutical Education by the Pennsylvania Society of Health-System Pharmacists. Each Action Agenda will be approved for one contact hour of continuing education (0.1 CEU).
Learning objectives and instructions for applying for CE are available at the PSHP CE Center.

The Pennsylvania Society of Health-System Pharmacists is approved by the American Council of Pharmaceutical Education as a provider of continuing education and complies with the criteria for quality continuing pharmaceutical education programming.

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