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ISMP Quarterly Action Agenda - July-September 2003


From the October 2, 2003 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 July and September 2003. Each item includes a brief 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 may also be visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses. See www.ismp.org/newsletters/acutecare/articles/A3Q03Action.htm for details.

I. Drug Storage, Standardization, and Delivery Devices
  • Abandon use of the error-prone "Rule of 6" (16, 17)

    Problem: New 2004 Joint Commission standards, as well as a National Patient Safety Goal, require standard concentrations of IV solutions and pharmacy preparation (when open) of all IV admixtures. These crucial safety measures represent a challenge in pediatric and neonatal units where nurses often prepare IV solutions using the error-prone "Rule of 6."

    Recommendation: Adopt standard concentrations for pediatric/ neonatal solutions, abandon use of the "Rule of 6," and have pharmacy prepare and dispense these solutions. Standard concentrations are also needed to maximize functionality of "smart" pumps, which can alert nurses to dosing and programming errors if standard concentrations and dose limits have been entered.

  • How sterile water bags show up on nursing units (19)

    Problem: Liter bags of sterile water for injection have been mistaken for IV solutions and administered IV to patients, causing hemolysis. These bags appear on patient care units in several ways: (1) materiels management staff have mistakenly stocked the bags on units; (2) leftover liter bags from malignant hyperthermia boxes (stored for diluting DANTRIUM IV [dantrolene]) have been accidentally added to floor stock after treatment; and (3) liter bags have been brought to (or stored on) the unit by respiratory therapy staff to humidify inspired air (using Fisher & Paykel devices, for example) for ventilated patients.

    Recommendation: Maintain pharmacy oversight of all pharmaceutical items distributed through materiels management. In malignant hyperthermia boxes, consider replacing liter bags of sterile water with 50 mL vials. If possible, use a different method of humidifying inspired air for ventilated patients (other vendors offer self-contained units that do not require use of sterile water bags).

  • Sequential compression devices (SCDs) connect to IV tubing (18)

    Problem: A hospitalized patient connected the air supply hose from his Albahealth SCD, used to prevent deep vein thrombosis, to his B. Braun needleless IV tubing, risking an air embolism. The connection was discovered before the patient was harmed.

    Recommendation: Investigate your SCDs (including brands other than Albahealth) to determine if such a misconnection could occur in your facility. If so, keep SCD tubing away from needleless IV tubing, and label the tubing to alert others that it supplies air.

  • PosiFlush (Becton, Dickinson and Company) syringes (19)

    Problem: PosiFlush 10 mL saline syringes with short-length plunger rods were used to dilute and administer cefazolin via a syringe pump. However, the pump clamp blocked the plunger rod from completing the infusion. PosiFlush syringes, approved only for flushing indwelling (e.g., PICC) vascular catheters, allow optimal pressure distribution during injection, but they are not indicated for other uses.

    Recommendation: Do not use these specially designed syringes to reconstitute or infuse medications via a syringe pump. Ideally, pharmacists should prepare all IV solutions or provide units with premixed products.

.II. Communication of Medication Orders
  • Prescribers may confuse lab tests with medications (14)

    Problem: Prescribers who use some computerized order entry systems could mistakenly order a lab test (e.g., drug assays and drug levels) instead of a medication if both options are identified using similar terminology and appear on the same screen.

    Recommendation: Establish different pathways for ordering drugs and laboratory studies so that both options cannot be viewed on the same screen. Carefully select the nomenclature to avoid confusion between drugs and lab tests.

  • Survey respondents report errors due to vaccine abbreviations (17)

    Problem: Practitioners appear uncertain whether the CDC's list of uniform vaccine abbreviations will reduce errors. Many have experienced errors when abbreviations were used, especially in orders.

    Recommendation: Use preprinted order forms for the most commonly used vaccines. When possible, list the vaccine's full generic name (and brand name if needed) on immunization schedules, computer screens, preprinted orders and protocols, and immunization forms (redesigned to provide space).

  • Avoid using "IN" for "intranasal" medications (18)

    Problem: With the increasing variety of intranasal medications (including the new nasal mist flu vaccine FLUMIST), anticipate errors if "IN" is used to abbreviate the route. "IN" could be misread as "IV" or "IM," or misheard as "IM."

    Recommendation: Don't use "IN" as an abbreviation for "intranasal." If an abbreviation must be used in pharmacy computer systems, use"NAS" (but not "NS," which could be read as normal saline).

  • Stop insulin when "holding" enteral feedings (18)

    Problem: A continuous enteral feeding for a diabetic patient was temporarily stopped for a CT scan, but his subcutaneous NPH insulin was not. His blood glucose dropped to 26 mg/dL.

    Recommendation: If a diabetic patient receiving enteral feedings is also receiving subcutaneous insulin, be sure to discontinue the insulin (or adjust the dose) if the enteral feedings are stopped, even temporarily. Prominently list these instructions on the patient's chart near the enteral feeding order and on medication administration records.

III. Drug Labeling, Packaging, and Nomenclature
  • Color-coding of ophthalmic products can contribute to errors (15)

    Problem: A color-coding system designed to help ophthalmologists and patients differentiate classes of medications has contributed to errors in pharmacies and nursing units. Similarities in corporate logos, fonts, and package sizes have also contributed to recent errors.

    Recommendation: Purchase ophthalmics within the same class from different vendors to minimize similarities in appearance.

  • FORADIL (formoterol fumarate) capsules for inhalation (15)

    Problem: Foradil is packaged as a capsule that requires a special inhaler to disperse the medication into the bronchi. Nurses and patients may assume that the capsules should be swallowed since the unit-dose packages do not bear a warning against this.

    Recommendation: Dispense the capsules and inhaler together. If loose capsules must be dispensed, apply a warning label to each package stating: "FOR INHALATION, using special inhaler only." Educate staff and patients in the proper use of this product.

  • SORIATANE (acitretin) and sertraline (ZOLOFT) (16)

    Problem: A handwritten order for Soriatane 25 mg was misread and dispensed as sertraline 25 mg. The error was discovered a week later by a nurse who routinely compared all medications she was about to administer to her patients' diagnoses.

    Recommendation: Always confirm that patients' drug therapy matches their diagnoses. New 2004 Joint Commission standards will require a documented diagnosis in the medical record for each medication, which should then be referenced by pharmacists and nurses.

  • PURINETHOL (mercaptopurine) and propylthiouracil (17)

    Problem: A child with leukemia missed 6 months of chemotherapy because propylthiouracil (antithyroid) was dispensed instead of PURINETHOL (mercaptopurine), an antimetabolite. Mix-ups in which Purinethol was dispensed instead of propylthiouracil have also been reported. Since propylthiouracil doses are often several hundred milligrams a day, mistakes that result in giving Purinethol at these high doses could cause harm.

    Recommendation: Don't store Purinethol and propylthiouracil in close proximity. Post shelf warnings and add computer alerts to remind staff about the potential for confusing these two drugs. When dispensing in outpatient pharmacies, match the drug's NDC number against the one listed in the computer database. Encourage prescribers to list both brand and generic names on orders for Purinethol.

IV. Other Discussion Items with Multiple System Elements
  • Safety issues with patient-controlled analgesia (PCA) (14, 15)

    Problem: PCA has considerable potential to improve pain management. But many factors in its application can lead to errors, some fatal. These factors include PCA by proxy, improper patient selection, inadequate patient monitoring, inadequate patient education, drug product mix-ups, practice-related problems, device design flaws, inadequate independent checks, and prescribing errors.

    Recommendations: Issue 15 provides a PCA safety checklist. Examples include: Don't use PCA for confused patients and young children. Use morphine as the opiate of choice. Separate morphine and hydromorphone in drug storage areas. Establish one standard concentration for each opiate in use. Frequently monitor patients' quality of respirations and be alert to signs of oversedation. Don't rely on pulse oximetry readings alone to detect opiate toxicity. Have oxygen and naloxone readily available. Teach surgical patients how to use PCA when they are alert (preoperatively), not after they have received anesthesia.

  • Similar safety needs for inpatient and outpatient chemotherapy (17)

    Problem: An oncology outpatient was given an overdose of NAVELBINE (vinorelbine) IV because the office nurse accidentally used 50 mg vials instead of 10 mg vials when preparing the dose, and the physician did not perform an independent double check.

    Recommendation: Outpatient oncology facilities should meet the same safety standards required for inpatient settings, including: preparation of chemotherapy in a sterile environment; documentation of lot numbers and diluents; an independent double check of chemotherapy preparation; consistent formatting of container labels; and pharmacy oversight of drug storage, labeling, preparation, and dispensing.

  • Preventing acetaminophen overdoses (16, 18, 19)

    Problem: Prescribers may order multiple acetaminophen-containing products for prn use (many on preprinted orders) without recognizing the potential for toxicity if all the products are administered as ordered.

    Recommendation: Use combination products without acetaminophen (e.g., DARVON), or with 500 mg of acetaminophen or less (e.g., DARVOCET A500). Implement automatic substitutions for products with higher doses, or if a cumulative dose could exceed more than 4 g daily. Track cumulative doses concurrently, or generate daily retrospective reports (from automated dispensing equipment) to monitor patients who have received more than 3 g daily. Build alerts in pharmacy computer systems to warn when prn doses could exceed safe limits. Also post warnings on medication administration records.


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.

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