ISMP Quarterly Action Agenda: July - September, 2000
From the October 3, 2001 issue
One of the most important ways to prevent medication errors
is to proactively seek and use knowledge from other organizations
that have experienced problems to prevent similar occurrences.
To promote such a process, administrative staff and an interdisciplinary
committee (e.g., Pharmacy and Therapeutics, medication safety
teams, process improvement/clinical safety groups, etc.) at
each practice site should review the following agenda to prompt
discussion and stimulate action to reduce the risk of errors.
The following selected items appeared in the ISMP Medication Safety Alert! between July - September 2001. 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. Agenda items are posted
on our web site and many product-related problems can be visualized
in the ISMP Medication Safety Alert! section. ACPE credit
is available for pharmacists (see www.ismp.org for details).
The American Society of Health Care Risk Management (ASHRM)
routinely provides the ISMP Quarterly Action Agenda to all
I. Look-alike/sound-alike drug names, ambiguous or look-alike
labeling and packaging
- LANTUS (insulin glargine [rDNA origin]) and LENTE
(insulin zinc suspension) (14) (16)
Problem: Confusion is possible with verbal or written
orders for Lantus, a new once-a-day insulin product with
a constant 24-hour blood level, and Lente, a more rapid
and shorter acting insulin. Using the letter L as an abbreviation
for Lente can also contribute to mix-ups.
Recommendation: Alert prescribers to potential mix-ups.
Prohibit the use of L as an abbreviation for Lente or Lantus
insulin and clarify all orders if received in this manner.
Remind nurses that Lantus insulin should be given daily
at bedtime, not in the morning like other insulins. Place
auxiliary warning labels on Lantus vials.
- SERZONE (nefazodone) and SEROQUEL (quetiapine)
Problem: Similarities in nomenclature with the antidepressant
SERZONE (nefazodone) and the antipsychotic SEROQUEL
(quetiapine) has led to 17 reported mix-ups. Poorly written
orders, storage near each other, and listing names sequentially
on computer screens have been contributing factors. Similar
instructions, dose ranges, and availability in 100 mg and
200 mg strengths also heighten the risk of errors.
Recommendation: Separate product storage and names
on computer screens or printed forms. Build computer alerts
and affix warning labels to products as appropriate. Advise
staff and patients about the potential for confusion.
- AGGRASTAT (tirofiban) and argatroban (15)
Problem: Name similarity between Aggrastat and argatroban
has led to confusion. In addition, although Aggrastat is
an antiplatelet drug and argatroban is a direct thrombin
inhibitor, each may be thought of as "anticoagulants." Label
confusion also has been reported with argatroban. The carton
states "100 mg/mL," but the vial size, 2.5 mL, is listed
far away from the concentration. The 250 mg total amount
is not specified. Errors are possible if staff concludes
that only 100 mg is in the vial.
Recommendation: Evaluate the potential for confusion
before adding either drug to the formulary. Clarify the
required drug's purpose prior to dispensing or administering
either drug. Provide practitioners with side-by-side comparisons
of the drugs for reference. Build computer alerts and place
reminders on drug containers and storage shelves. Highlight
the volume of the vial size on argatroban drug cartons.
- ROXANOL (morphine sulfate) (19)
Problem: Instead of the prescribed 10 mg dose, a
patient in a long-term care facility received 10 mL of a
concentrated form of ROXANOL (morphine sulfate),
20 mg/mL (200 mg).
Recommendation: When possible, avoid concentrated
morphine solution and use commercially available 10 mg/5
mL or 20 mg/5 mL (especially in unit dose cups). Dispense
concentrates only for patients who require higher than usual
doses due to severe chronic pain. Affix auxiliary labels
to help differentiate the concentrated product and remove
it immediately from unit stock once discontinued.
- NIMBEX (cisatracurium besylate) (16)
Problem: Nimbex is available in a 20 mg/10 mL (2
mg/mL) multiple dose vial, and a 200 mg/20 mL (10 mg/mL)
single dose vial meant for preparing infusions. With almost
identical packaging and labeling, mix-ups have been reported.
Recommendation: Until Abbott Laboratories makes planned
label enhancements, draw attention to the different strengths
by circling the concentration. If possible, have pharmacy
dispense Nimbex infusions to avoid storing the two different
concentrations in patient care units.
II. Dangerous abbreviations, confusing dose designations,
and other unsafe ways of communicating orders
- "DTO" (18)
Problem: "DTO 0.7 mL PO q4h" was interpreted as "tincture
of opium, deodorized," which contains 10 mg/mL of morphine.
However, the prescriber intended the infant to receive "diluted
tincture of opium," or paregoric, which contains 25-fold
less morphine (0.4 mg/mL).
Recommendation: Resist using coined names, contrived
abbreviations or other unofficial designations for medications.
Establish a policy to prohibit the use of dangerous abbreviations.
If tincture of opium, deodorized, must be stocked along
with paregoric, differentiate these products by using auxiliary
warnings on labels and alerts that appear during the order
III. Patient identification and education
- DURAGESIC (fentanyl patch) (19)
Problem: Patients have been known to misapply fentanyl
patches. In a recent case, a confused elderly woman misunderstood
directions for use and applied six patches at once "wherever
it hurt" on her body, resulting in opiate toxicity.
Recommendation: Patient selection criteria for fentanyl
patch use must include an assessment of the patient's ability
to understand information about proper dosing, administration,
- Measurement devices for oral liquids (17)
Problem: A child died when the cap of a hypodermic
syringe used during administration of an oral suspension
flew off and became lodged in his throat. The hypodermic
syringe was given to the parents to measure the medication.
The cap appeared to be part of the syringe, especially since
the suspension could be withdrawn into the syringe without
Recommendation: Hypodermic syringes should never
be used for oral medication administration. Parents should
be instructed to use a proper measuring device such as a
measuring cup or ORAL syringe. While caps on many oral syringes
do not pop off easily, parents and staff should be alerted
to ensure removal before administration.
- Bar code technology (15)
Problem: Only about 2% of hospitals employ bar code
technology to dispense or administer medications.
Recommendation: Prepare now for future implementation
by establishing a comprehensive unit dose system.
IV. Other discussion items
- Medication errors and human factors (13)
(19) While it is widely recognized that system failures
cause errors and that well-designed systems and technology
offer the best chance of preventing errors, we should devote
equal attention to understanding how the human system operates
and the conditions that adversely affect its function. Researcher
Anthony Grasha, Ph.D., Professor of Psychology at the University
of Cincinnati, provides study data on cognitive functions,
psychosocial factors that influence performance, and tools
to enhance work patterns.
- Nonpunitive culture and accountability (16)
(17) (18) (19) Review and discuss our recent article on
a shared model of accountability. Discuss survey findings
on the perceptions of a nonpunitive culture. See our website
(www.ismp.org/newsletters/acutecare/articles/nonpunitive.html) and newsletter
articles for details.
- Evidence-based practices (15) The Agency for Healthcare Research and Quality (AHRQ) released a report that listed more than 70 evidence-based practices known to improve patient safety (http://www.ahrq.gov/clinic/epcix.htm). The National Forum for Health Care Quality Measurement and Reporting (NQF) will use the AHRQ data to establish consensus to guide agencies that may require hospitals to adopt some or all of the practices. Now is the time to assess these practices and degree of implementation in your organization.
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.
The Pennsylvania Society of Health-System
Pharmacists is approved by the American Council
of Pharmaceutical Education as a provider of continuing
education and complies with the criteria for quality
continuing pharmaceutical education programming.