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ISMP Quarterly Action Agenda: April - June, 2001

From the July 11, 2001 issue

ISMP Quarterly Action Agenda: April - June 2001 One of the most important methods for preventing medication errors 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 errors. The following selected items appeared in the ISMP Medication Safety Alert! between April - June 2001. Each item includes a description of the problem, recommendations for safe medication practices, and the issue number (in parentheses) to locate additional information. The American Society of Health Care Risk Management (ASHRM) provides the ISMP Quarterly Action Agenda to all its members. Agenda items are also posted on our web site (, and, in many cases, product-related problems can be visualized in the ISMP Medication Safety Alert! section of our web site. ACPE credit is available for pharmacists. See our web site for details. I. Look-alike/sound-alike drug names, ambiguous or look-alike labeling and packaging

  • BREVIBLOC (esmolol) premixed infusion bags (7) Problem: The foil outer-wrap lists the drug's identity on one side only. When the bag is turned over, its appearance is identical to the Baxter dopamine premixed bag, which is also in a foil wrap and labeled on one side only. Further, like certain other Baxter premixed products, the plastic IV bags of Brevibloc are printed in black type with red type for the drug name and strength. Recommendation: Do not store the premixed product in patient care areas. Use the special medication labels that Baxter includes in the shipping cartons. The premixed solution should be used only if pharmacy dispenses the product for each patient after affixing the special labels to both sides of the plastic bag.
  • COLAZAL (balsalazide) and CLOZARIL (clozapine) (9) Problem: Orders for COLAZAL (balsalazide), a drug used to treat mild to moderate ulcerative colitis, could easily be confused with the antipsychotic CLOZARIL (clozapine). Colazal is available as a 750 mg tablet taken three times daily. Clozaril is available in 25 mg and 100 mg tablet strengths, but dosing can range as high as 900 mg a day, which can overlap with the tablet strength of Colazal. Also, orders for Clozaril 75 mg, written improperly with a terminal zero (75.0 mg) increase the chance of a mix-up. Recommendation: A mix-up between these drugs could be dangerous, making it critical to communicate the medication's purpose on all prescriptions for either drug. We also recommend installing alerts in your computer and applying auxiliary labels to the drug containers.
  • Confusion between glass bottles of D5W and premixed nitroglycerin bottles (10) Problem: An emergency department nurse erroneously hung a bottle of plain D5W instead of premixed nitroglycerin. Both solutions are available from several manufacturers in 500 mL glass bottles. D5W is on hand to prepare admixtures of drugs such as CORDARONE (amiodarone) that are incompatible or less stable in plastic (PVC) bags. While Cordarone use is increasing in the ED and ICU, most glass bottles that nurses handle are premixed nitroglycerin, making it easy to confuse it with D5W. Recommendation: Educate staff about the potential problem, reinforcing the importance of reading labels. A change in supplier for one of these items would decrease appearance similarities. For the same reason, purchasing premixed nitroglycerin in 250 mL bottles and D5W in 500 mL bottles would also help. Pharmacy should prepare and send them to patient care areas when possible to ensure an added check.
  • ANZEMET (dolasetron mesylate) injection ampuls (11) Problem: The font size used for the name and strength of the drug on the ampul label was recently decreased by more than half and the color was changed from black on white to a light green on white. These changes make the new label nearly impossible to read. Also, the glass ampul itself has gone from fully scored (easily opened) to a "One Point Cut," which fractures if it isn't opened precisely as instructed. Recommendations: Abbott Laboratories, who co-markets the drug with Aventis, has asked their sales force to provide customers with information about the proper way to open the ampul. Aventis is promising an improved label. If problems aren't satisfactorily resolved, an alternative 5-HT3-receptor antagonist might be considered.
  • OCCLUSAL-HP and OCUFLOX (ofloxacin) (11) Problem: A physician prescribing via computer chose OCCLUSAL-HP (17% salicylic acid, topical) from an alphabetical product list and sent the prescription to a hospital outpatient pharmacy with directions to "use daily as directed." The patient was being treated for "pinkeye" and the physician intended to select the ophthalmic antibiotic, OCUFLOX (ofloxacin). Recommendation: It is essential that pharmacists have information about the purpose of each prescription in order to properly advise patients and protect them from potential harm. Patient counseling can also help in detecting errors.
II. Dangerous abbreviations, confusing dose designations, and other unsafe ways of communicating orders
  • Verbal orders confused as dosing range (11) Problem: A prescriber's telephone order for XANAX (alprazolam) 0.125 mg prn was misheard by a nurse as "Xanax .1 to 5 mg" and transcribed as a dose range of "Xanax .1 - 5 mg prn." Recommendation: Use computerized screening of orders to prevent excessive medication doses. Place limitations on verbal orders and be sure staff is aware of this potential problem. When intended, dose ranges should always be associated with specific clinical parameters.
  • Errors due to misinterpreting dangerous dose expressions and abbreviations (9) Problem: Misinterpretation of "naked" decimal points and other dangerous dose expressions and abbreviations continue to harm patients. A 9-month-old baby girl died after the baby's physician prescribed morphine ".5 mg IV" and the unit secretary transcribed the order by hand onto a medication administration record (MAR) as "5 mg." An experienced nurse followed the directions on the MAR and gave the baby 5 mg of IV morphine initially and another 5 mg dose two hours later leading to the fatality. Recommendation: A link to a table of dangerous abbreviations and dose expressions most often associated with misinterpretation and patient harm (as reported to the USP-ISMP Medication Errors Reporting Program) is available on our web site with the May 2, 2001 issue of this newsletter. Please use this list to establish and enforce a list of abbreviations and dose expressions that should never be used. The Joint Commission on Accreditation of Healthcare Organizations has agreed to publish an issue of Sentinel Event Alert regarding dangerous abbreviations and dose designations.
III. Other discussion items
  • Fentanyl transdermal systems (8) Prescribers trying to manage patients with acute pain have occasionally recommended fentanyl transdermal systems to opiate-naive patients, which could lead to tragic outcomes. Even when patients are opiate tolerant, incorrect conversion from an oral opiate to fentanyl patches, difficulty titrating doses, combined oral-topical therapy, and variability in absorption have led to opiate overdoses. Dosing should not exceed 25 mcg/hr in opiate-naive patients. Fentanyl patches are best reserved for opiate-tolerant patients with chronic pain. Base the initial dose on the total daily dose, route, potency, and characteristics of the drug the patient has been taking previously, narcotic tolerance, and the patient's general condition. New prescriptions should be accompanied by a dose calculation sheet and verified by a pharmacist.
  • Bowel prep drugs pose problems in renal patients (10) Serious consequences to renal patients may go unrecognized when doses for some bowel preparations are too high. Fleet products such as Fleet enemas and Fleet Phospho-soda contain more than 160 mM of phosphate per dose. Magnesium, in magnesium citrate solution and milk of magnesia, can accumulate in a patient with renal dysfunction. These items often are maintained in floor stock and treated with impunity. Special precautions are needed to alert nurses to contraindications for renal patients. Information on electrolyte content of each product should be listed clearly on floor stock items along with a warning that the product may cause problems for patients with renal impairment. Restricted access may be necessary to limit removal of doses from automated dispensing systems prior to a pharmacist's clinical review of the order. During order entry, computer systems should warn practitioners about electrolyte content when these agents are about to be used for patients with decreased renal function.
  • Errors of Omission (12) Medication errors are hard to detect, but some that occur during the prescribing phase may be especially elusive and elicit controversy as to whether they are truly an error or an acceptable difference in professional judgment. Errors of omission are less obvious when prescribers fail to order medications for which there are evidence-based studies documenting significant reduction in morbidity or mortality. Pharmacists can play a pivotal role in the application of evidence-based knowledge by actively reviewing applicable research, disseminating the information to the medical staff, and establishing clinical monitoring functions for selected outcomes. Daily pharmacists' interactions with prescribers should be face-to-face to assist in the selection of appropriate drug therapy, including those prescribed at discharge. Pharmacists should document interventions and share aggregate results with prescribers to generate ideas for improvement.
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