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ISMP Medication Safety Alert

ISMP Quarterly Action Agenda - January-March 2005


From the April 7, 2005 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 items appeared in the ISMP Medication Safety Alert! between January and March 2005. Each item includes a 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 can also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses.

I. Issues Related to Communication of Prescribed Medications

  • Mistaking mg for mL when dosing units are not specified (1)

    Problem: A pharmacist asked a technician to quickly prepare "morphine point one five, six syringes" for a neonate, but each syringe was filled with 0.15 mL (0.3 mg), not 0.15 mg (0.075 mL) as intended. The pharmacist caught the error, but in another case, a toddler died after receiving 0.8 mL (8 mg) of oral morphine instead of 0.8 mg based on a verbal order that did not include the dosing units.

    Recommendation: When accepting a verbal order or instructions to fill a stat medication order, be sure the information is complete (including dosing units), write it down, and verify its accuracy by reading it back to the originator. In the pharmacy, prepare all (including stat) medications using the order copy and label rather than verbal instructions.

  • Joint Commission and error-prone abbreviations (3)

    Problem: Requiring pharmacists and nurses to clarify all orders containing error-prone abbreviations has resulted in interdisciplinary friction. Thus, the Joint Commission will no longer consider organizations compliant even if pharmacists or nurses call a prescriber for clarification of abbreviations.

    Recommendation: Assign full responsibility of prescriber compliance for avoiding error-prone abbreviations to the medical staff. Ensure that nurses and pharmacists support educational efforts and avoid using error-prone abbreviations themselves.

  • Handling "hold" orders (6)

    Problem: Warfarin was placed on hold before an endoscopy, but not resumed after the procedure. The patient suffered a stroke 6 days later. An order to hold a medication can also result in resuming the medication too soon.

    Recommendation: If a patient is on daily medications based on lab results, the pharmacy profile and nursing MAR should reflect this as an ongoing active order listing the drug, route, and frequency, with a notation that a dose must be prescribed each day. If medication doses are not guided by daily lab values, hold orders should not be accepted unless they include specific instructions for when to resume the medication. However, all medications held for a procedure should be rewritten fully after the procedure.

II. Issues Related to Labeling, Packaging, and Nomenclature
  • CAMPATH (alemtuzumab) label changes (1)

    Problem: Campath packaging includes three 30 mg (10 mg/mL) ampuls in one carton, but just one ampul is needed for a typical dose. A technician thought the entire carton contained 30 mg and prepared a 90 mg dose by mistake.

    Recommendation: A new 30 mg/mL concentration is now being packaged in single vial cartons according to the manufacturer, Berlex Laboratories. Be sure to isolate the old concentration from stock, make the necessary changes in the pharmacy computer, add directions for admixture, and notify staff about the change.

  • Phenylephrine mistaken for metoclopramide (2)

    Problem: A patient undergoing surgery inadvertently received phenylephrine 10 mg IV instead of metoclopramide after a look-alike phenylephrine vial was retrieved from a metoclopramide bin. Similar instances of misplaced vials had been encountered before at this hospital, but widespread action had not been taken to reduce errors with these and other look-alike products.

    Recommendation: Standardize the organization of anesthesia carts and store similar-looking vials away from each other. Consider attaching a bag of diluent to phenylephrine vials to further differentiate it from metoclopramide.

  • Brand name extension with KAOPECTATE (bismuth subsalicylate) (4)

    Problem: The brand name, Kaopectate, is now being used for two products with different ingredients: a well-known anti-diarrhea agent and a stool softener (docusate calcium).

    Recommendation: Alert staff and patients that there are now two Kaopectate products, each for opposing indications. Verify the drug's indication if Kaopectate is prescribed.

  • GLUCAGEN (glucagon) bar code could cause errors (5)

    Problem: Glucagen is packaged as a vial of lyophilized powder (1 mg) and a separate vial of sterile water for reconstitution (1 mL). Each vial is labeled with the same bar code. If the diluent is scanned, a hypoglycemic patient could receive water instead of active drug.

    Recommendation: Warn practitioners of the risk of errors if you use a bedside bar-coding system. Currently, defacing the bar code on the diluent vial is the only way to eliminate the risk of error.

  • Atropine and adenosine vial mix-ups (5)

    Problem: Vials of atropine 0.4 mg/mL and adenosine 6 mg/2 mL from Baxter can easily be confused due to similar appearance.

    Recommendation: Segregate these vials and affix auxiliary labels if both must be available in the same area.

  • Drug product confusion in the sterile field (5)

    Problem: Ethyl alcohol from an unlabeled basin was drawn into a syringe and injected into a patient's face instead of lidocaine, which was also in an unlabeled basin. The patient suffered partial facial paralysis.

    Recommendation: Develop and implement policies and procedures for safe labeling of all medications and solutions within sterile fields (including in the ED, radiology, and cardiac catheterization labs).

III. Issues Related to Drug Information, Storage, and Standardization

  • ABRAXANE (paclitaxel protein-bound particles for injectable suspension) and TAXOL (paclitaxel) (5)

    Problem: Abraxane, a new solvent-free formulation of paclitaxel that does not require premedication with corticosteroids and antihistamines, is typically dosed at 260 mg/m2 every 3 weeks. If confused with conventional paclitaxel, which is dosed at 175 mg/m2 every 3 weeks, harm could result.

    Recommendation: Be sure oncology staff are aware of the error potential with this new drug. Ask oncologists to include the brand name if prescribing Abraxane, and distinguish it from conventional paclitaxel on computer screens (e.g., refer to Abraxane as "nanoparticle-paclitaxel").

  • Safety challenges with DEPODUR (morphine sulfate extended-release liposome injection) (3)

    Problem: DepoDur is a new one-time extended-release epidural injection that provides pain relief for about 48 hours. Safety challenges with this drug include: (1) identifying patients who have received DepoDur to prevent administration of additional pain medications and ensure proper monitoring, and (2) potential confusion with DURAMORPH (morphine sulfate, preservative free).

    Recommendation: Implement preprinted orders for DepoDur that include documentation of the time and date of injection, appropriate monitoring parameters, and bold warnings that the patient should not receive other pain medications, CNS depressants, or any epidural drugs. (Removal of the epidural catheter after administration of DepoDur helps ensure this.)

  • Safety is a team effort (1)

    Problem: Maintenance staff filled empty detergent containers with used hydraulic fluid, which was later used to wash thousands of surgical instruments.

    Recommendation: Never reuse medical containers. Include all non-professional healthcare workers in patient safety efforts and ensure that they recognize the many safety hazards that are under their control. (Visit our online store for information on a video, Patient Safety Requires a Team Effort, with vignettes that show how non-clinical employees can unknowingly play a role in a medication-related error.)

  • Joint Commission, the Rule of 6, and the Broselow tape (4, 6)

    Problem: A calculation error related to the Rule of 6 may have contributed to an infant's death recently when it led to a misplaced decimal point and the preparation of a dopamine infusion 10 times more concentrated than required. Unrelated to this event, use of the Broselow tape is another source of nonstandard concentrations, which also does not comply with the Joint Commission National Patient Safety Goal.

    Recommendation: Establish standard concentrations for pediatric critical care drugs and abandon use of the Rule of 6. In future revisions, the Broselow tape will only provide dosing information for IV push medications. However, continue to use the tape for pediatric emergencies until standard concentrations have been established in your facility. The Joint Commission is considering our suggestion to allow hospitals a sufficient amount of time for transitioning to standard concentrations during pediatric emergencies, as was granted to hospitals that used the Rule of 6.

IV. Other Discussion Items

  • Make a commitment to "pro-change" in your organization (1)

    Problem: Only half of hospitals surveyed in the 2004 ISMP Medication Safety Self Assessment for Hospitals have a convened interdisciplinary team that routinely analyzes and uses published error experiences from other organizations to proactively target improvements in the medication use process.

    Recommendation: Assign a specific professional(s) to research published error reports and new advances in medication safety. Routinely bring this information to the current team that reviews internal medication safety issues to develop an action plan for proactive change ("pro-change").

  • Survey indicates that formulary myths still exist (3)

    Problem: A reader survey shows that myths such as "The specialist knows best," "The formulary interferes with clinical freedom," and "Widespread use equals drug of choice" are still present in today's hospital environments.

    Recommendation: Hold frank discussions with the medical and professional staff about the purpose of the formulary to dispel common myths and stress its importance as a crucial safety measure.

  • Provide a "sterile cockpit" for critical healthcare duties (6)

    Problem: Distractions cause errors. The airline industry has addressed this by rigorously enforcing restrictions in potentially distracting behavior during critical duties.

    Recommendation: Provide healthcare staff with a similar "sterile cockpit" during crucial steps in the medication use process.

  • Measuring medication safety (5)

    Problem: Measuring medication safety is fundamental to improvement, but identifying practical and accurate methodologies for data collection has long been a problem. Historically, healthcare has relied on practitioner reporting of errors, which is highly inaccurate and counterproductive.

    Recommendation: Process measures, structure measures, balancing measures, and outcome measures must be tracked to improve medication safety. See the full newsletter article for examples of each type of measure and how to collect data to demonstrate whether improvement efforts have been successful.

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.

Access the CE for Pharmacists
(CE has expired)

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses

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