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ISMP Quarterly Action Agenda: April - June, 2000

From the July 12, 2000 issue

One of the most important methods for preventing adverse drug events is for organizations to be proactive by seeking and using knowledge from other organizations that have already experienced problems. To make a significant impact on error prevention efforts, administrative staff and an interdisciplinary committee at each 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 April and June, 1999. Each item includes a description of the problem, recommendations for safe medication practices and the issue number (in parenthesis) to locate additional information. The American Society of Health Care Risk Management (ASHRM) provides the quarterly ISMP Action Agenda to all its members.

I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • LANTUS (insulin glargine [rDNA origin]) and LENTE (insulin) (9)
    Problem:Lantus, a new long acting insulin, may be mistaken for "Lente" insulin, which has a more rapid effect and shorter duration of activity than Lantus. Wrong time errors are also possible as Lantus is given once daily at bedtime. If simply ordered as "daily," those administering the drug may assume it should be given in the morning like other insulins.
    Recommendation: Use computerized reminders to alert staff when orders for either insulin are processed. Use block letter characters when prescribing. If verbal orders are necessary, prescribers should request staff to read back their transcriptions, spelling the name. Orders for Lantus should include "daily at bedtime" instructions.
  • ATGAM (anti-thymocyte globulin equine) and THYMOGLOBULIN (anti-thymocyte globulin rabbit) (10)
    Problem:These two anti-thymocyte globulin products have been confused. The products are derived from different animal species and have dramatically different doses.
    Recommendation: Prescribers should always include the animal species or brand name (or both) along with the order. Orders stating only "anti-thymocyte globulin" or "ATG" must be clarified.
  • Folinic acid confused with folic acid (11)
    Problem:Folinic acid, a synonym for leucovorin, is a useful antidote to folic acid antagonists. A pharmacist correctly dispensed leucovorin calcium for a folinic acid prescription. A nurse thought the order was for folic acid and borrowed a dose from another patient.
    Recommendation:Use only the official name. To reduce possibility of confusion with LEUKERAN (chlorambucil), refer to the drug as leucovorin calcium. Educate nurses about the danger of "borrowing" doses and prohibit the practice.
  • DIAMOX (acetazolamide) and DIABINESE (chlorpropamide) (12)
    Problem: A pharmacy technician used a generic version of Diabinese (chlorpropamide) 250 mg to prepare a prescription for Diamox (acetazolamide) 250 mg. The dispensing pharmacist mistook chlorpropamide as the generic name for Diamox.
    Recommendation: Store drug containers apart from one another. Design computer mnemonics to prevent these names from appearing together on screens. Eliminate acetohexamide and chlorpropamide from the formulary or place them in locked cabinets or hazardous substance storage areas. To avert mix-ups, tell patients to talk to their pharmacists whenever prescriptions are dispensed for these drugs.

II. Misinterpretation or miscommunication of drug orders

  • "IU" misinterpreted as "IV" (10)
    Problem: The abbreviation "IU" (international units) in an order for "Vitamin E 100 IU daily" was misinterpreted as IV (intravenous) because the route of administration was omitted. This led to someone drawing capsule contents into a syringe for IV administration.
    Recommendation: For drugs dosed in international units, eliminate "international" and spell the word "units" instead of using the abbreviation "U." Prescribers must always include the route of administration within drug orders. Medication safety training in professional schools and organizations should include recognition that oral products are not suitable for IV use. Include warnings against such actions in hospital staff newsletters.
  • Confusing computer-generated Medication Administration Record (MAR) format may be a source of errors (12)
    Problem: Errors are possible when MARs list the available dosage strength (the dose dispensed) in bold on the top line and the patient specific dose below if the two doses differ. In one case, a patient received cyclosporine 50 mg IV after a nurse misinterpreted the 50 mg/mL dosage strength listed in bold on the top line as the patient's actual dose, which was listed as 30 mg on a subsequent line.
    Recommendation: Hold regular pharmacy-nursing meetings to identify MAR format problems and include information system staff to work with the pharmacy computer vendor to make necessary changes. Accentuate the patient's dose, not the available dosage strength.
  • Oral liquid medications may be more vulnerable to errors than previously recognized (13)
    Problem: Improper dosing, incorrect or misunderstood directions for use, improper compounding, and inaccurate measurements of liquid oral medications have led to many errors.
    Recommendation: Prescribers should include the calculated metric weight dose and its mg/kg basis to facilitate independent recalculation by pharmacists and nurses. Set weight-based dose limits in the pharmacy computer system for oral liquid medications. Before discharge, educate caregivers about proper measurement, provide an oral syringe when feasible, and remind them to bring the measuring device to the pharmacy for a demonstration. In retail pharmacies, segregate oral liquid medications from other prescriptions to alert clerical staff to call a pharmacist for counseling when patients pick up the drug.

V. Discussion Items

  • Patient safety movement calls for reexamination of multiple dose vial (MDV) use (12)
    CDC reported that a contaminated 20 mL MDV of saline was the source of transmitting hepatitis C virus to three patients. Research shows that 25% of practitioners reentered MDVs with a contaminated needle. For about two hours, contaminating organisms may remain viable in MDVs before the preservative fully exerts its effect. In the pharmacy, the risk of contamination is minimal when MDVs are used for compounding in an aseptic environment. However, in patient care units, CDC recommends using prefilled syringes or single dose vials for inexpensive but widely used substances to reduce the risk of contamination.
  • Vincristine administered intrathecally instead of methotrexate (7)
    Another patient received a fatal dose of vincristine intrathecally after it was mixed up with a methotrexate syringe during the injection process. Physicians who are focused on performing a lumbar puncture may overlook the syringe label and accidentally administer an IV medication intrathecally. To prevent errors, wrap intrathecal drugs within a sterile bag, then wrap again in a towel or bag labeled for intrathecal use. Unwrap immediately prior to injection and require a documented independent check before administration. Dispense IV and intrathecal medications at separate times to different locations. Administer intrathecal medications in a designated location. Establish a list of drugs that can be administered intrathecally (or epidurally) and ban all other injectable drugs from lumbar puncture rooms.
  • Include consumers in your error-prevention programs(10)
    Don't pass up the opportunity to use the increased media scrutiny to start talking to the public and patients about medical errors and building stronger relationships with the media. While we have been working hard to enhance patient safety within our organizations, we must now come out from behind the scenes to help educate the public about errors, their causes, and how we - providers and patients together - can prevent errors. Respond to medical error news coverage with a press release or opposing editorial. Acknowledge the public's concerns with honesty and demonstrate your commitment to safety with examples of how you have made it difficult for staff to err. Emphasize the things they can do to enhance their own safety and include patients/consumers in internal quality improvement and safety initiatives.
  • More needs to be done to protect pediatric patients from medication errors (8)
    An ISMP survey on pediatric medication practices shows that improvement is needed. The least prevalent safety practices included listing the mg/kg dose as part of the drug order (to facilitate recalculation) and having clinical pharmacists actively participate on units (even ICUs). The pharmacists dispensed only 81% (mean) of pediatric drugs in unit doses and 84% (mean) of parenteral solutions. Non-critical care units reported lower adherence to the safety practices suggested in the survey, but it's important to implement the same safety practices for all pediatric drug therapy, regardless of the patient's setting of care.
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