Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook

ISMP Medication Safety Alert

ISMP Quarterly Action Agenda - July-September 2005

From the October 20, 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 July and September 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

  • Erroneous list of home medications (18)
    Problem: A newly admitted patient was incorrectly prescribed fluoxetine 100 mg instead of fluvoxamine 100 mg, as erroneously listed on the patient's history and physical. A pharmacist detected and corrected the error after asking a family member to bring the medication to the hospital for identification.  
    : As demonstrated above, an interdisciplinary medication reconciliation process (now a Joint Commission National Patient Safety Goal) can help prevent medication errors by validating the history of medications taken at home. Also consider adding these two medications to the organization's list of look-alike/sound-alike drugs.
    Sliding scale insulin coverage (19)
    Problem: Sliding scale insulin orders may lead to misinterpretations if they are not clearly communicated. In one case, a physician prescribed insulin coverage for a blood sugar between 0 and 180, potentially leading to the administration of insulin to a patient with a low or normal blood sugar.
    : Standardize sliding scale insulin coverage and use standard order sets to clearly communicate orders. If possible, do not use sliding scale insulin coverage as a routine method of blood glucose control. 
  • II.  Issues Related to Medication Delivery Devices

  • False glucose results with point-of-care testing (18)
    Problem: Administration of certain medications can result in erroneously high glucose values when monitoring blood sugars with certain point-of-care glucose meters. In one case, the IV administration of an immunoglobulin product formulated with maltose produced a falsely elevated glucose meter reading and the inappropriate escalation of a patient's insulin dose.
    : Check the table at to see if the glucose meter used in your organization can cause a similar problem. If so, create special alerts in the pharmacy computer system and on MARs to remind staff about the potential for false glucose readings when entering orders for products that may affect accuracy.
    Use oral syringes for NIMOTOP (nimodipine) (15)   
    Problem: For dysphagic patients with a nasogastric (NG) tube, Nimotop can be prepared by extracting the contents of the soft gelatin capsule into a syringe, administering it via the NG tube, and flushing with 30 mL of saline. However, once in a parenteral syringe, the drug has been given IV accidentally, causing severe hypotension, cardiovascular collapse, and death. 
    : When Nimotop is prescribed for NG tube administration, have the pharmacy prepare the doses in amber oral syringes (stable for up to 30 days) and dispense them in labeled, light-protected bags. Pharmacists should also warn nurses about the danger of accidental IV injection. Put a reminder in the computer and on the drug container to bring attention to the problem. 
  • III.  Issues Related to Drug Labeling, Packaging, and Nomenclature

  • Phenytoin and heparin vials (15)
    Problem: Vials of heparin (5,000 units/mL, 1 mL fill in 2 mL vial) and phenytoin (100 mg/2 mL vial), both manufactured by Baxter Healthcare Corporation, look alike and have led to dispensing errors.
    : Consider purchasing one of the products from another manufacturer. If both products continue to be supplied by Baxter, separate their storage and enhance content identification by affixing cautionary labels to the vials (without obscuring label information) before placing them in stock.  
    DEPO-SUBQ PROVERA 104 (medroxyprogesterone acetate suspension) (16)
    Problem: Depo-SubQ Provera 104 is a new formulation of the existing Depo-Provera product, intended for subcutaneous administration in a dose of 104 mg every 3 months. However, part of the drug name could be left off or misaligned when prescriptions are written, leading to potential confusion with Depo-Provera, which should be administered IM. If this happens, the old formulation may be administered subcutaneously.  
    : Notify all staff of this new formulation. Carefully review all Depo-Provera prescriptions to assure the correct formulation and route of administration has been prescribed.
    Adult and pediatric hepatitis B vaccines
    Problem: The packaging of the adult and pediatric strengths of Merck's hepatitis B vaccines look alike and the labels do not provide sufficient visual differentiation despite a difference in border color. The resemblance between the products has led to dispensing errors.
    : Separate the pediatric and adult strengths in all areas where these products are stocked. In addition, consider affixing auxiliary labels to better distinguish the products.  
    Hidden information on ceftriaxone label (18)
    Problem: The 250 mg, 500 mg, and 1 g vials of ceftriaxone (manufactured by Sandoz) are difficult to differentiate from one another. The label wraps around the bottle and the strength immediately follows the drug name where it cannot be seen well unless the vial is rotated. The strength is also buried within the text below the drug name, making it virtually impossible to discern. Recommendation: Stock a single strength of the Sandoz product, and obtain alternate strengths from a different manufacturer.
    TOPROL-XL (metoprolol) and TOPAMAX (topiramate) (18)
    Problem: FDA and manufacturers alerted the medical community about dispensing mix-ups between Topamax and Toprol-XL. Product names are similar, and the "X" in XL for Toprol-XL looks like the ending of Topamax. The imprint on the 25 mg Topamax tablet, which lists "TOP" on one side and "25" on the other, can facilitate belief that it could be Toprol-XL 25 mg. Recommendation: Separate the storage of these products. Use both brand and generic names when prescribing these medications to differentiate the two drug names.  
    SALAGEN (pilocarpine) and selegiline (19)  
    : Several mix-ups have occurred between the branded drug Salagen and a similarly named generic drug selegiline. Both products are available in 5 mg tablets, although selegiline is also available as ELDEPRYL, a 5 mg capsule.
    : Prescriptions for either drug should include both the brand and generic names. Pharmacists and nurses should also match the drug's indication to the patient's diagnosis to confirm the correct medication. Patients should be alerted to the possibility of confusion between these two products, especially when picking up outpatient prescriptions.
  • IV.  Issues Related to Drug Information, Drug Delivery, and Drug Storage

  • Drug delivery problems (16)
    Problem: A patient received another patient's chemotherapy despite verification by two nurses, due in part because pharmacy dispensed two different patients' chemotherapy drugs together within a single ziplock bag. After emptying the contents of the bag in the room, the nurses unexpectedly discovered both IV solutions. After verification of the correct solution, the nurse accidentally picked up the wrong IV bag and administered the medication.     
    : Dispense only one patient's medications in a ziplock bag (or envelope, etc.). Involve the patient in a final check to avert errors.
    New fentanyl warnings (16)  
    : Patients and healthcare providers may not be aware of the dangers of transdermal fentanyl products. Several fatal errors were recently reported. An opiate-naïve woman died after applying several patches to the site of her pain, and a child died after applying one of his mother's patches.
    : Thoroughly review the recent alert from Janssen ( as well as the July 15, 2005, FDA Public Health Advisory about changes to product labeling. Screen patients to ensure that they are appropriate candidates for this therapy at the doses prescribed. Educate patients to ensure safe use and disposal of the patches. Documentation of the patch's application site can also help guard against inadvertently applying multiple patches. 
    Preventing errors with neuromuscular blocking agents (19)
    : Neuromuscular blocking agents have been inadvertently administered to patients who were not receiving ventilatory support. Some patients have died or sustained permanent injuries. Most incidents have taken place outside operating rooms, emergency departments, and other critical care areas.
    : Allow floor stock of these agents only in the OR, ED, and critical care units. Sequester in both refrigerated and non-refrigerated locations. Affix fluorescent red warning labels on products that note: "Warning: Paralyzing Agent-Causes Respiratory Arrest."  
  • V.  Other Discussion Items

  • High-reliability organizations (HROs) (14, 15)
    Problem: Healthcare is a highly complex, error-prone industry. There are a number of other industries that are equally complex and error-prone, and where the consequences of an error are just as dire. Yet, many of these high-hazard industries have excellent safety records that far exceed healthcare organizations. These industries are called HROs. The differences between healthcare organizations and HROs are deeply rooted in their cultures.
    Recommendation: Recurrent culture of safety themes in HROs (e.g., strategic safety goals and plans; proactive, outward focus) offer an opportunity for healthcare organizations to reflect on how our respective cultures differ and how we can establish a culture of safety to reduce patient harm. 
    Safety still compromised by computer weaknesses (17)
    Problem: Alarming findings from an ISMP survey demonstrate that pharmacy computers are vastly unreliable when used to detect and correct prescribing or order entry errors. There has been little improvement with pharmacy computer systems over the past 6 years since our last survey. Recommendation: Do not depend on this technology to detect all potentially harmful errors. Test your organization's computer system ( to identify weaknesses and share this information with your computer vendor for improvement.
    Apologies gain momentum (17)
    Problem: A decade ago, physicians were told to avoid making apologies to patients for errors because it could lead to problems if they were sued.
    Recommendation: Today, some healthcare executives, insurers, and physicians are embracing disclosure and apology because they believe it will reduce malpractice claims, and it's ethically the right thing to do. All organizations should establish similar policies to acknowledge errors and offer fair compensation for expenses related to the medical injuries.
    Contingency plans for outsourced services (19)
    Problem: Injectable products made by Central Admixture Pharmacy Service (CAPS) were recently recalled due to sterility problems. 
    Recommendation: Develop contingency plans for potential interruptions in product or drug-related services that are outsourced.

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.

Access the CE for Pharmacists
(CE Expired)

Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved