ISMP Quarterly Action
Agenda: April - June 2002
From the July 10, 2002 issue
One of the most important ways to prevent medication
errors is to proactively seek and use knowledge 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 April
- June 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. The American Society
of Health Care Risk Management (ASHRM) routinely provides
the ISMP Quarterly Action Agenda to all its members.
ACPE credit is available for pharmacists (see www.ismp.org
I. Problematic nomenclature, labeling, and
packaging of products
- AVINZA (morphine sulfate extended release) and INVANZ
(ertapenem) confusion (8, 10)
Problem: Confusion is possible between Avinza, a
once-a-day capsule for 24-hour pain control, and Invanz,
a new parenteral antibiotic from Merck. The name "Invanz"
also has been mistaken as "IV Vanc."
Recommendation: Always include dose and route of
administration when communicating orders for Invanz. Do
not use word stems such as "Vanc" for vancomycin,
or statements such as "put the patient on Avinza"
or "start Avinza," where dose and route are not
- FEMARA (letrozole) and FEMHRT (ethinyl estradiol/norethindrone
acetate) mix-up (7)
Problem: An oncologist prescribed Femara for a
postmenopausal woman with recurrent breast cancer, but
the patient received the hormone replacement drug FEMHRT.
These names look and sound similar and both are prescribed
to women for conditions related to menopause. Recommendation:
Prescriptions for Femara should include the strength to
differentiate it from FEMHRT. Place reminders on drug
containers and in computer systems. Warn patients about
the risk of mix-ups.
- Generic drug name mix-ups (13)
Problem: A physician confused valacyclovir (VALTREX)
with valganciclovir (VALCYTE). The generic (and brand
names) sound very much alike and are easily confused,
and both have uses associated with cytomegalovirus. In
another error, anakinra (KINERET), an interleukin 1 blocker,
was prescribed but amikacin (AMIKIN) was dispensed.
Recommendation: Use both brand and generic names
when prescribing these medications.
- FORADIL (formoterol) and TORADOL (ketorolac) mix-up
Problem: A handwritten Foradil prescription for
an asthma patient was mistaken for the nonsteroidal anti-inflammatory
drug Toradol. The names also may sound alike when communicating
Recommendation: For this name pair, as well as
others cited above, review the prevention suggestions
outlined in "What's in a name? Ways to prevent dispensing
errors linked to name confusion," which appeared
in our June 12, 2002 issue.
- Unsafe labeling of respiratory therapy medications
and certain injectables in plastic vials (10)
Problem: Some respiratory therapy medications and
certain injectable products are packaged in low-density
polyethylene (LDPE) vials that look nearly identical.
Drug names, strengths, lot numbers and expiration dates
are embossed on the containers in transparent, raised
letters, which are almost impossible to read. FDA will
no longer permit paper labels or colored inks applied
directly to LDPE containers because the potential for
adverse effects of volatiles in label glue is not well
Recommendation: When packaging alternatives exist
(especially for injectables), pharmacy and group purchasing
organizations should avoid LDPE ampuls with embossed labels.
Do not store respiratory medications together in a single
bin. Affix auxiliary labels before dispensing. At least
one manufacturer (Nephron) provides medications as unit
doses with labeled outer packaging. Ensure respiratory
medications are ordered through the pharmacy.
- Etomidate and neostigmine mix-up (12)
Problem: Two patients undergoing electro-convulsive
therapy felt discomfort during their procedures when they
received neostigmine, an anesthesia reversal agent, instead
of the intended etomidate, a general anesthetic. Etomidate
vials (2 mg/mL) and neostigmine vials (1:1,000) are packaged
by Bedford Laboratories in the same size (10 mL vials)
and have black and gray lettering and numbers on the label.
Recommendation: If you carry these two products,
purchase one from a different manufacturer.
- ARIXTRA (fondaparinux) confused with Anti-Xa lab
Problem: There were two near misses involving pharmacists
who confused orders for the lab test, anti-factor Xa (expressed
as "Anti-Xa"), with the once-a-day, low molecular
weight heparin (LMWH) product, Arixtra.
Recommendation: Order the lab test as "anti-factor
Xa." Orders for Arixtra always should specify the
drug, dose, route and frequency.
- Removing plastic IV containers overwraps allows
Problem: If premixed IV bags are removed from their
protective overwrap, the drug's concentration increases
over time as the fluid volume within the container decreases
due to evaporation of fluid through the bag wall.
Recommendation: Don't remove premixed IV bags from
their protective overwraps far in advance of dispensing.
Once removed, consider environmental factors (e.g., humidity,
temperature) and the material used by the manufacturer
to ensure proper storage. For less frequently used products,
place a label with the expiration date on part of the
bag that does not come into contact with the solution.
- Dual-chamber IV bags (13)
Problem: A dual-chambered IV bag (lower chamber
with amino acids, upper chamber 50% dextrose) used for
parenteral nutrition (PN) solution was not mixed prior
to dispensing. The patient received a concentrated solution,
including electrolytes and insulin.
Recommendation: Consider adding multivitamins to
each PN bag to assure inactivated bags are readily recognized
(split the daily dose so that the yellow vitamins are
visible in each bag). Incorporate independent double checks
of work and a checklist to assure that the full contents
of the bag have been mixed. Nurses also should check bags
to assure proper mixing.
II. Dangerous abbreviations, confusing dose designations,
and unsafe ways of communicating orders
Computer screen abbreviations (8)
Problem: Software-related problems can lead to
omitted characters or the display of wrong characters.
For example, the Greek letter character "mu"
for "micro" does not always translate well or
it might not be seen at all in certain word processing
Recommendation: When expressing drug doses in word
processing or other programs, avoid using symbology (including
apothecary symbols). Also avoid the handwritten "mu"
character because it can look like an "m," which
could be misunderstood as milligram. The safest abbreviation
to use for microgram is mcg.
Hazardous abbreviations (10)
Problem: The abbreviation "AD" used for
right ear (aura dexter) has been mistaken for a variety
of other meanings: OD (right eye - oculus dexter); QD
(once daily); PO (by mouth); and "as directed"
on prescriptions. One patient received eardrops in the
eye. Using AS for left ear or AU for each ear also might
Recommendation: These abbreviations should be avoided.
Erroneous daily dosing of medications for weekly
III. Other discussion items
Problem: Fatalities have been reported in patients
who have been prescribed a once-a-week dose of methotrexate
(e.g., for rheumatoid arthritis, asthma, psoriasis, inflammatory
bowel disease, myasthenia gravis, inflammatory myositis).
Relatively few medications are dosed in this manner and
the drug has been accidentally prescribed or dispensed
daily instead of weekly.
Recommendation: Build alerts in electronic prescribing
and pharmacy systems and configure them to avoid defaulting
to a daily dosing schedule. Verify proper dosing, confirm
the correct dosing schedule on medication administration
records and prescription labels, and educate staff and
patients. Prescribe and dispense unit-of-use dose packs
(e.g., RHEUMATREX by Lederle), which helps to reinforce
the weekly dosing schedule.
- Topical lidocaine toxicity (10)
Lidocaine is extensively absorbed, up to 35%, after topical
administration to mucous membranes. This can lead to toxic
plasma levels if large amounts are used, such as during
bronchoscopy. Extra care is needed in infants, the elderly,
and those with liver or cardiac impairment. Protocols
should specify a maximum dosage. Make sure new house staff
are aware that topical lidocaine is absorbed from mucous
- Pediatric medication error prevention guidelines
ISMP and the Pediatric Pharmacy Advocacy Group (PPAG)
have published the first comprehensive consolidation of
recommendations to reduce the risk of medication errors
in the pediatric population (also endorsed by The Society
of Pediatric Nurses) in The Journal of Pediatric Pharmacology
and Therapeutics. The guidelines also are available on
the ISMP website.
- Gathering creative solutions to prevent errors
A community hospital placed suggestion boxes and forms
by the elevators to prompt information about safety issues
and concerns. The hospital invites patients, visitors,
and staff to provide their perspective and creative solutions
for improvements. This may be a valuable, untapped resource
that can help lead to improvements in safety and patient
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