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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 unit stock.
    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 diarrhea.
    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 (10)
    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 Devices

  • 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 bolus doses.
    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 10-month-old baby.
    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% caps (12)
    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 (13)
    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 be fatal.
    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 IV bag.
  • 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 (8)
    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 (11)
    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 driving limit).
    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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