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
I. Drug Storage, Standardization, and Delivery Devices
.II. Communication of Medication Orders
- Abandon use of the error-prone "Rule of 6"
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
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
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.
III. Drug Labeling, Packaging, and Nomenclature
- Prescribers may confuse lab tests with medications
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
Survey respondents report errors due to vaccine
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"
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
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
Stop insulin when "holding" enteral feedings
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
IV. Other Discussion Items with Multiple System Elements
- 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
FORADIL (formoterol fumarate) capsules for inhalation
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
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.
- 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
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,
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.
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