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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - July - September 2004

From the October 21, 2004 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 2004. 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 visualized in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for pharmacists and nurses.

I. Issues Related to Communication of Prescribed Medications

  • Fentanyl order miscommunicated (14)

    Problem: An order for fentanyl was heard as "5,200 mcg per hour" and read back to the prescriber for verification. A pharmacist called the physician and learned that he had prescribed fentanyl "50 to 100 mcg per hour."

    Recommendation: When reading back verbal orders, express doses in single digits such as "5-2-0-0" to avoid confusion.

  • Eliminating dangerous abbreviations (16)

    Problem: Achieving compliance with the Joint Commission's dangerous abbreviation initiative has led to strained relationships between physicians and nurses/pharmacists who must call for clarification. Some physicians no longer return pages in a timely manner.

    Recommendation: This effort requires peer-to-peer interaction and support from hospital and medical staff leaders. Compliance is also needed on all forms of communication (e.g., computer screens, drug labels, administration records, preprinted orders).

II. Issues Related to Medication Delivery Devices
  • Misprogrammed PCA pumps (15)

    Problem: One patient died and another recovered after nurses misprogrammed Deltec CADD-Prizm PCS Pain Control System pumps (model 6101). An unrecognized feature allowed the pump to default back to a prior setting when the current setting was not confirmed within minutes.

    Recommendation: Perform a failure mode and effects analysis on any new PCA pump considered for use. Introduce new pumps in a small setting to ensure that the safety features are operational. Match the sequence of information on PCA labels with the information that must be entered into the PCA pump. Highlight the PCA concentration on labels.

  • Inadvertent drug injections into inflation ports (18)

    Problem: IV tubing and parenteral syringes can be connected accidentally to some medical devices that have balloon inflation ports (e.g., Foley catheters, cuffed tracheostomy tube, cuffed endotracheal tube, gastrostomy tube with balloon), thus allowing inadvertent medication administration or unintended solutions into the balloon.

    Recommendation: Clinicians and manufacturers should work collaboratively to identify error potential through failure mode and effects analysis when introducing new tubes and catheters into healthcare systems and, when the risk of injury to patients is high, affix auxiliary labels to the inflation ports.

  • Syringe of air injected during radiologic procedure (18)

    Problem: A patient received a syringe full of air IV via an automated power injector used to administer contrast media during a CT scan. The syringe had already been used on the previous patient. The patient experienced seizure activity.

    Recommendation: If you use a power injector, ensure that only qualified staff are handling the contrast media, and that there is a consistent process for setting up the syringes, verifying the syringe contents and patient, observing the patient during injection, and discarding the used syringes.

III. Issues Related to Drug Information

  • Improvised dosing charts can cause errors (13)

    Problem: A patient received nitroglycerin at 200 mcg/minute rather than the ordered 60 mcg/minute when a handwritten dose conversion chart led to misprogramming of the pump, primarily because corresponding dosage units had not been listed for numbers that appeared in two columns.

    Recommendation: A formal approval process and ongoing oversight is needed to ensure standardization and proper design of dosing tables. With standard concentrations and commercially available premixed drugs, the process can be simplified by pharmacy application of computer-generated or commercially printed labels that include dosing tables.

  • Dosing errors with CeeNU (lomustine) (14)

    Serious errors have occurred when CeeNU is administered daily rather than once every 6 weeks. Two recent errors, one an order entry error in a hospital, and the other a dispensing error from a community pharmacy, led to harm and prolonged hospitalization.

    Recommendation: Program warnings to dispense "single dose only" into order entry systems. Use unit-of-use dose packs and enhance labels for patients. Require counseling for every CeeNU dose dispensed. Require initial and ongoing training for staff who handle oral chemotherapy.

  • Don't use immediate-release nifedipine for hypertensive crisis (15)

    Problem: The effect of immediate-release nifedipine in adults is unpredictable, and several well-documented reports describe serious side effects, from profound hypotension to death, when this drug is used during a hypertensive emergency, even if the capsules are swallowed whole (not just sublingual use).

    Recommendation: Alternatives for acute episodes of hypertension include: oral clonidine, captopril, or labetalol; enalaprilat IV; or nitroprusside infusion.

  • New formulation of CYTOXAN (cyclophosphamide) (17)

    Problem: Bristol-Myers Squibb (BMS) has recently discontinued the lyophilized formulation of the injectable drug. The new formulation does not contain mannitol so there's very little powder in each vial. To prevent hypotonicity, the drug must be reconstituted with sodium chloride rather than sterile water.

    Recommendation: Alert staff to the new reconstitution directions and amend any drug admixture resources that contain sterile water as the diluent for cyclophosphamide.

  • Surgical fires with ethyl chloride continue (17)

    Problem: A physician applied ethyl chloride spray to an area on a girl's forehead, which ignited when a cautery device was turned on. The container has poorly visible warnings about flammability. The patient suffered first-degree burns to her ear.

    Recommendation: Reevaluate the need for this product on your formulary, as there are often safer alternatives, especially for topical anesthesia. Add auxiliary labels to warn about flammability.

IV. Issues Related to Drug Labeling, Packaging, and Nomenclature

  • ACTOS (pioglitazone) and ACTONEL (risedronate) (13)

    Problem: A pharmacist entered "ACTO" into the computer to find ACTOs, but mistakenly chose ACTOnel on the screen. The patient received the wrong medication for 16 days.

    Recommendation: Match both brand and generic name to confirm the correct drug has been selected when using the first few letters of a drug name. Consider adding computer alerts.

  • MUCOMYST (acetylcysteine) and MUCINEX (guaifenesin) (13)

    Problem: Two patients received the wrong medication due to mix-ups between Mucomyst and Mucinex. Although neither patient was harmed, serious injury could occur if Mucomyst was not administered to treat an acetaminophen overdose or prevent contrast media induced nephrotoxicity.

    Recommendation: Confirm the drug's indication before dispensing and administering these medications.

  • Deadly mix-ups with hydromorphone and morphine (13, 14)

    Problem: Instead of morphine 10 mg IM, a patient received hydromorphone 10 mg (equivalent to 60-70 mg of morphine). Both drugs were available in the same strength in a narcotic drawer. These mix-ups are among the most common and serious with high-alert drugs. This patient died, as have others.

    Recommendation: Reduce or eliminate hydromorphone from unit stock. Provide these drugs in different strengths or forms (e.g., prefilled syringes of hydromorphone 1 mg) if both must be available in unit stock. Store each drug in a separate bin/drawer. Use tall man letters and/or the brand name, DILAUDID, on labels and computer screens. While morphine may be available via the override feature in automated dispensing cabinets, do not allow hydromorphone to be removed from the cabinet before pharmacy screening of the initial order.

  • NOVOLIN 70/30 (70% NPH human insulin isophane suspension, 30% regular human insulin) and NOVOLOG MIX 70/30 (70% insulin aspart protamine suspension, 30% insulin aspart) (14)

    Problem: Recent mix-ups between Novolin 70/30 and Novolog Mix 70/30 have occurred. In the past, the more familiar product, Novolin 70/30, was administered instead of the newer Novolog Mix 70/30 product. More recent mix-ups have occurred when "Mix" was not included in orders for Novolog Mix 70/30.

    Recommendation: Consider limiting the insulin analog 70/30 mixtures on the formulary to just a single product. If both products are available, place reminders about confusion on storage locations and differentiate names on labels and computer screens by using tall man letters (e.g., NovoLIN, NovoLOG MIX).

  • Errors continue with conventional and liposomal doxorubicin (14)

    Problem: Nurses administered the liposomal form of doxorubicin, DOXIL, to patients instead of the conventional form, doxorubicin hydrochloride.

    Recommendation: Ensure that nurses who administer chemotherapy are aware of the potential for this error. Store the two medications separately in the pharmacy, and allow only trained pharmacy staff to prepare chemotherapy. Add auxiliary labels to Doxil containers and storage shelves, and use the brand and generic names to differentiate the liposomal form of the drug.

  • Ratio dose expression confusing (15, 16)

    Problem: A 16-year-old with priapism received an intracavernous irrigation of 4 mL (4 mg) of undiluted 1:1,000 epinephrine. A 1:1,000,000 epinephrine solution should have been used. The physician thought that the 1:1,000 ratio on the 1 mg/mL vial meant that 1 mg of drug had been prediluted with 1,000 mL of fluid. The patient arrested and could not be resuscitated.

    Recommendation: Do not stock large vials (30 mL) of epinephrine 1:1,000. If this concentration is necessary, stock only the 1 mL ampuls so the need for multiple vials can serve as an alert. ISMP has petitioned USP, asking for the elimination of ratio expressions on epinephrine labels.

  • Tetanus toxoid and tuberculin purified protein derivative (PPD) (16)

    Problem: The Centers for Disease Control and Prevention has published a warning about accidental administration of tetanus toxoid-containing vaccines instead of PPD. The products have similar names and packaging.

    Recommendation: Purchase these products from different manufacturers whenever possible. Remove tetanus toxoid and PPD from unit stock if feasible and dispense from the pharmacy. Affix warning stickers on outer cartons if both products are available. List the full vaccine names to prevent confusion.

  • AMARYL (glimepiride) and REMINYL (galantamine) mix-ups (18)

    Problem: Several reports have described the administration of Amaryl in place of Reminyl, leading to potentially severe hypoglycemia.

    Recommendation: Ensure that practitioners are aware of the risk of mix-ups, especially with handwritten orders. Confirm that patients are diabetic before dispensing or administering any antidiabetic medication. FDA and the drug manufacturers will be taking action to reduce the risk of errors.

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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