ISMP Quarterly Action
Agenda - April-June 2005
From the July 14, 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 topics appeared in the ISMP Medication Safety Alert! between April and June 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 viewed in the ISMP Medication Safety Alert! section of our website.
I. Issues Related to Communication
of Prescribed Medications
- Drug name abbreviations (7)
Problem: Three drug name abbreviations (DCN, DPH,
PROXL) with multiple meanings, depending on the prescriber,
led to several errors. In one case (DPH), a patient received
an unintended dose of diphenhydramine instead of phenytoin
(formerly diphenylhydantoin). While a pharmacist was clarifying
the order, the nurse administered a dose retrieved from
Recommendation: Prohibit the use of drug name abbreviations.
Ask prescribers to use full generic and/or brand names.
Alert nurses immediately if an order needs clarification,
particularly for medications available in unit stock.
Slash mark (/) and "cc" cause error (9)
Problem: Amoxicillin was prescribed in a concentration
that was not available in the pharmacy. The available
concentration was used and the directions were changed
to "Take 4 cc (4/5 teaspoonful)." The patient's
parents did not understand "cc" and mistook
the slash mark in 4/5 to mean 4.5. The child received
4.5 teaspoonfuls three times daily and developed severe
Recommendation: Do not use "cc" or slash
marks (/). Provide counseling for all new prescriptions,
especially if the directions for what is dispensed differ
from what was originally prescribed, and if a liquid dose
must be measured.
- QID and AD on "do not use" list not necessary
Problem: Organizations may reduce their success
with eliminating dangerous abbreviations by prohibiting
abbreviations that are less prone to serious errors.
Recommendation: The use of QID has not led to significant
errors and should not be included in "do not use"
lists. While abbreviations for "ears" (e.g.,
AD) and "eyes" (e.g., OD) have been mixed up,
including just one set of these abbreviations in a "do
not use" list (preferably AD, AS, and AU since instilling
ear drops into an eye is more serious than the opposite
error) should be enough to prevent misinterpretation.
- Many safety issues with SYMLIN (pramlintide acetate)
insulin adjunct (12)
Problem: Symlin is dosed in mcg, but the manufacturer
recommends using a dosing chart and an insulin syringe
to measure each dose. Using an insulin syringe, a patient
or practitioner could become confused and withdraw 30
units, for example, for a prescribed 30 mcg dose. Prescribers
have expressed the dose in "units" to match
the syringe, also potentially causing confusion. A Greek
µ for mcg is used in the patient's dosing instructions
in the Medication Guide, which could be misread as the
more familiar but dangerous abbreviation "u" for units.
Recommendation: Patient education and written dosing
instructions are a vital component of Symlin therapy.
Patients should also be provided with comprehensive monitoring
forms on which to document all insulin and Symlin doses
and corresponding glucose levels. A consult to home care
services and a certified diabetes educator is suggested.
- Inaccurate patient medication histories (8)
Problem: Poor communication about patients' medication
histories at vulnerable transition points (e.g., admission,
discharge, transfer) is responsible for up to 50% of medication
errors and 20% of harmful adverse drug events.
Recommendation: Initiate a medication reconciliation
process (now a Joint Commission National Patient Safety
Goal). Obtain a complete medication history upon admission,
transfer, or discharge; have physicians use this list
when prescribing medications at these vulnerable transition
points; and have another person reconcile the prescribed
medications to ensure accuracy. See the article for a
full description of the process.
II. Issues Related to Medication Delivery
- Patient tampering with opioid infusion pump (7)
Problem: A patient with a history of chronic pain
was admitted to the hospital and permitted to use the opioid-infusion
pump he brought from home. It was later discovered that
the patient had knowledge of lock level and clinician bolus
codes, and had altered pump settings to administer higher
Recommendation: Use only hospital-approved pumps
to administer opioids. Track doses dispensed and administered
by comparison with the prescribed doses. Shield pump-programming
codes from non-clinicians. Consider changing codes temporarily
for patients at risk for tampering, as long as the new codes
can be securely communicated to all who need the information.
- Smart pumps delete "drug library" if
all batteries drain (10)
Problem: Baxter Colleague CX pumps will delete
all hospital-specific data in the "drug library"
and revert to factory settings if the main and back-up
lead acid batteries drain, and the maintenance lithium
battery drains. When plugged in, "FC 199" displays
on the screen if this has occurred.
Recommendation: If you use these pumps, consider
attaching a sticker to instruct nurses to avoid using
pumps that display "FC 199," and to return them
immediately to bioengineering for reprogramming.
- Strangulation by IV tubing (11)
Problem: The April 30, 2005, Lancet describes a
tragic, fatal case of strangulation by IV tubing of a
Recommendation: Warn staff, parents, and caregivers
about strangulation risks imposed by IV tubing, oxygen
tubing, and monitor leads. Use accessories to stabilize
these flexible lines and ensure appropriate supervision.
Also consider using video surveillance.
- Early release of estrogen from CLIMARA (estradiol
transdermal system) (11)
Problem: A patient experienced hot flashes after
sun tanning while wearing Climara. The estrogen was released
early due to excessive patch warming while sunning, leaving
less drug in the patch for later in the week.
Recommendation: Educate patients to avoid sun tanning
on the patch area.
III. Issues Related to Drug Labeling,
Packaging, and Nomenclature
- Tetanus toxoid and tuberculin purified protein derivative
(PPD) mix-ups (9)
Problem: Despite a 2004 Centers for Disease Control
and Prevention warning, eight more people were accidentally
given tetanus toxoid instead of PPD. Look-alike packaging
of Sanofi Pasteur products contributed to the errors.
Recommendation: Remove tetanus toxoid and PPD from
unit stock if feasible and dispense from the pharmacy. Separate
the storage of these products, and affix warning stickers
on storage bins and outer cartons in areas where both products
are available. List the full vaccine names to prevent confusion.
- Color change for TIMOPTIC (timolol maleate) 0.25%
Problem: Containers of Timoptic 0.25% previously
had light blue caps; the 0.5% strength had yellow caps.
Now, all strengths have yellow caps, potentially leading
to confusion between the two strengths.
Recommendation: Alert practitioners about this
new potential for errors.
- Organ storage solution (VIASPAN) resembles IV bag
Problem: A pharmacist received what looked like
a plastic liter bag of IV solution with other products
returned for credit, but the bag actually contained Viaspan,
which is used for flushing and storage of organs during
procurement. The organ procurement team had left the bag
behind. IV administration of the solution would likely
Recommendation: Review your processes for stocking,
storing, and handling organ storage solution to avoid
this risk. If possible, purchase organ storage solution
in 2 liter or 5 liter bags so it looks less like a typical
- Error-prone table in ACETADOTE (acetylcysteine)
package insert (11)
Problem: A physician wrote for "Acetadote
150 mg/kg in 200 mL D5W over 15 minutes, then in 4 hours
infuse 50 mg/kg in 500 mL D5W." There should not
be a 4-hour waiting period after the loading dose, but
the physician had relied upon a table in the package insert
which states "in 4 hours" instead of "over
4 hours" when referring to the maintenance dose.
Recommendation: Cumberland Pharmaceuticals is updating
the labeling, but inform practitioners of the potential
for error until changes are made.
- Rifampin and rifaximin (XIFAXAN) confusion (12)
Problem: A patient received rifampin after a pharmacist
misread an order for a nonformulary drug, rifaximin. After
three doses, a nurse recognized the mistake, the drug
was stopped, and the patient was not harmed.
Recommendation: Require the prescriber to provide
the drug's indication when ordering a nonformulary product.
- Use of only generic names could lead to errors
Problem: The 2005 USP Convention members adopted
a resolution to encourage the use, in practice settings,
of generic names only for new single-active ingredient
products marketed after January 1, 2006. This would not
prevent all errors, as there are many look-alike generic
name pairs. Practitioners could also encounter difficulty
recalling and spelling generic names, leading to more
errors or the use of error-prone abbreviations.
Recommendation: Encourage prescribers to use both
generic and brand (when applicable) names for problematic
look-alike name pairs. Electronic orders can also reduce
the risk of misinterpreting drugs with look-alike names.
IV. Issues Related to Drug Information,
Drug Storage, and Staffing Patterns
- Monitoring phytonadione (Vitamin K1) use (9)
Problem: When using phytonadione to reverse the effects
of warfarin before a procedure, its long-term effects may
last up to a week, causing prescribers to dangerously increase
warfarin doses over several days post-procedure.
Recommendation: Pharmacists should determine the
circumstances for all orders of phytonadione 10 mg or higher.
If it's being used to reverse the effects of warfarin pre-procedure,
suggest a lower dose and ensure the physician understands
that the effects of phytonadione will linger after the procedure.
- Glacial acetic acid (9, 13)
Problem: Despite warning statements on glacial
acetic acid containers, concentrated forms of this chemical
have been dispensed instead of diluted forms, leading
to patient injuries. For example, a 31-year-old paraplegic
patient who had leg wounds irrigated with the undiluted
chemical for 2 days required bilateral leg amputations.
Recommendation: Remove glacial acetic acid from
pharmacy stock and purchase diluted acetic acid (even
vinegar might work) or outsource its preparation. If this
is not possible, dilute the product in the concentrations
needed immediately upon delivery. Place prominent alert
messages on storage shelves and bottles. Only accept orders
that include the exact strength necessary.
- An exhausted workforce increases the risk of errors
Problem: Long work hours and the fatigue that results
represent a serious threat to patient safety. Among its
many effects, fatigue diminishes the ability to recognize
important but subtle changes in a patient's health and
reduces the ability to deal with the unexpected. In fact,
prolonged wakefulness leaves a person with the equivalent
of a blood alcohol concentration of 0.1% (above the legal
Recommendation: Provide managers with information
about the risks of fatigue, circadian rhythm disturbances,
and approaches to optimize performance. Set limitations
on the hours worked each day and week, and for specific,
potentially fatiguing physical and mental tasks. Whenever
possible, recognize the circadian rhythm principles when
designing work schedules. Planned breaks and naps, light
therapy, and access to nutritious meals can also help
combat the effects of fatigue.
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.
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of Health-System Pharmacists is approved by the American
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