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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - october - december 2006

From the January 25, 2007 issue

One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and 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 senior leaders 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!Ò between October and December 2006. 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. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on ISMP’s list of high-alert medications. Many product-related problems can be viewed in the ISMP Medication Safety Alert!Ò section of our website. The Action Agenda is also available for download ( in a Word format that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each Agenda item. Continuing education credit is available for pharmacists and nurses at:


Serious tissue injury with IV promethazine (PHENERGAN)(22)
Problem:IV administration of promethazine has led to repeated cases of severe tissue damage that often required surgical intervention, including fasciotomy, skin graft, and even amputation. A recent ISMP survey highlighted new concerns and ideas for managing this risk.
Recommendation:The recommendations deemed to be of the greatest value by survey respondents included: diluting the drug in 10-20 mL; limiting the concentration (25 mg/mL) and initial dose (6.25 or 12.5 mg); providing alerts to practitioners; injecting the drug into a running IV using the port furthest from the patient’s vein; administering the drug slowly over 10 minutes; remaining with the patient during the injection; and advising patients to report any IV site discomfort. Other recommendations can be found on Table 1 in the full article at:

fe practice with prefilled saline flush syringes (23)
Problem:Medications are being reconstituted using prefilled saline flush syringes. The saline is injected into the vial, mixed with the medication, and then withdrawn into the syringe still labeled as saline. If the syringe leaves the practitioner’s hands before administering the drug, it may be used by another practitioner as a saline flush.
Recommendation: Educate staff regarding the serious risks associated with this practice. Medications should always be dispensed in the most ready-to-use form possible. If dilution or reconstitution must occur on the unit, supply staff with labels that may be applied to the final product.

Luer-access mechanical valve connectors (25)
Problem:Luer-access mechanical valve connectors that facilitate needleless injections through IV catheters or tubing can accidentally dislodge from the catheter hub when unscrewing the syringe; thus, the catheter end is exposed to air, which has resulted in bleeding and air embolus.
Recommendation: Until this problem can be corrected by industry, alert staff to this serious potential error as well as monitoring for signs and symptoms of bleeding and air embolus.

Key bounce and keying errors (21)
Problem:Medication errors have resulted from pressing once on an infusion pump’s number key and getting an unintended repeat of that same number. This occurs when the key is softly or partially pressed for a time, as one might do if programming a pump from an odd angle. Errors have also resulted from accidentally hitting a number key twice, or intentionally hitting the key twice because the corresponding number did not appear immediately on the screen.
Recommendation: Always compare the patient’s prescribed therapy on the medication administration record to the final displayed pump settings before starting the infusion. Stand directly in front of the pump when programming it and listen for one beep to correspond with each number programmed. Require an independent double check of pump settings for selected high-alert medications. Use smart infusion pumps with functional dose-range checking technology.

Responding to harmful errors (20)
Problem:When medical errors occur, hindsight bias and external pressure can lead to finger pointing during immediate analysis of the event. This sometimes leads to ill-conceived employment terminations or unwarranted disciplinary actions.
Recommendation: All practice sites should have a well-designed readiness plan in place to handle medical errors that harm patients, if they occur. Internal and external notification about the event, interaction with and disclosure to the patient/family, treatment of staff involved in the error, handling media inquiries, investigation of the event, and processes for improvement should be included in the plan. For more information, visit:

Look-alike bags of sterile water and sodium chloride (24)
Bags of sterile water for inhalation and intravenous sodium chloride, both manufactured by Cardinal Health, have the potential to be confused with one another as the bags are similar in appearance and color.
Recommendation: Separate respiratory solutions from storage of IV solutions and other medications, and affix auxiliary warning labels to the sterile water bags. Never hang sterile water or any respiratory solutions on IV poles; rather, hang on special poles that attach to the ventilators.

Automated dispensing cabinet (ADC) stocking errors (21)
According to error reports sent to ISMP and USP, the top ten drugs stocked in ADCs that were involved in medication errors include: morphine, heparin, oxycodone, diltiazem, ketorolac, meperidine, dopamine, hetastarch, methylergonovine, and promethazine.
Recommendation: A pharmacist (or pharmacy technician, if necessary) should double check all products pulled for restocking of ADCs before the medications leave the pharmacy. Ideally, bar code technology should be used when selecting and stocking ADC products, when removing them for administration, and before being administered to a patient.

Minibag's tubing cap can occlude medication flow (21)
PharMEDium uses blue plastic caps to seal its epidural preparations. If pump tubing is accidentally connected to the blue cap instead of the administration port on the bag, patients may fail to receive any drug.
Recommendation: Alert practitioners to this safety issue. Check IV pumps for an upstream occlusion alarm or air sensor as this feature can detect this particular problem by indicating that medication is not being infused.

Caution with ZYDIS technology (24)
ZELEPAR (selegiline) has been recently marketed in a form that uses Zydis technology. This formulation has the potential to be confused with ZYPREXA ZYDIS (olanzapine) when the medication is prescribed simply as “Zydis.”
Recommendation: If “Zydis” alone is prescribed, clarify which drug is intended in the Zydis formulation before dispensing.

BAXTER heparin 10,000 units/mL and diphenhydramine 50 mg/mL look-alike vials (22)
An error was reported in which heparin was dispensed instead of diphenhydramine. The drugs were stored near one another and had similar blue and white packaging.
Recommendation: If your institution stocks these products, consider purchasing one of them from an alternative manufacturer. Error potential should be considered when new products are brought into the pharmacy or when the manufacturer is changed for an existing product; consider where the product will be stored, its proximity to other drugs, and how it will be used outside the pharmacy.

Risks with pen injectors (24)
Numerous errors when using pen injectors have been reported, most often related to their use as a multiple-dose vial on inpatient units; error-prone device design; dispensing errors related to look-alike drug names and product packaging; confusing volume and dose; treating the available dose in the pen as a single dose; and inadequate patient education.
Recommendation: Conduct a failure mode and effects analysis on any pen device being considered or used in your organization. Also ensure that staff are educated about how to use the pen before dispensing it. Contribute to the pool of knowledge about pen injectors by reporting problems to ISMP so safe practices can be identified and disseminated.

LANTUS (insulin glargine [rDNA]) and APIDRA (insulin glulisine [rDNA]) OptiClik (23)
Using the OptiClik device for insulin may lead to dosing errors because the digital numbers displayed in the dose window could be misread (e.g., 25 looks like 52, 21 looks like 12) if the pen is held upside down, like a left-handed person may hold it.
Recommendation: Demonstrate to patients how to insert a new cartridge, attach a needle, measure the dose, and administer it. Illustrate the proper way to hold the device so the number in the dose display window is viewed correctly. Have the patient demonstrate proper use of the device.

Otic and optic route confusion (21)
Eardrops have been accidentally administered in the eyes, particularly when the drops were stored side-by-side, or when the sound- and look-alike terms “otic” and “optic” were confused when entering the directions for use. Two thirds of the errors examined by the Veterans Administration involved drug administration errors; 1 in 5 involved erroneous instructions from the pharmacy; 1 in 10 took place during self-administration.
Recommendation: Place an auxiliary label on the dropper bottle to specify “ear” or “eye” drops. Separate eardrop and eye drop vials on pharmacy shelves and medication carts. Confirm the medication with the patient before administration, and administer eye drops and eardrops on different schedules. Teach patients to keep the drops in the outer carton, as they often include a picture of an ear or eye to help prevent mix-ups.

Reporting “error-reporting rates” to board members (20)
Problem: Reporting the growth of an internal “error-reporting rate” has been misunderstood at administrative and board meetings as an increase in actual errors, rather than a positive step towards keeping patients safe.
Recommendation: Organizational leaders should educate administrative staff, board members, and other staff about the value of error reporting, which includes potential hazards and risks that could cause harm as well as errors that were caught before they reached the patient. Leaders should stress that a “rising error-reporting rate” reflects an increase in reporting, not necessarily an environment that has become less safe.

Reporting “error-reporting rates” to board members (24)
Problem: FDA and Baxter notified healthcare professionals of revisions to the warnings’ section of heparin prescribing information. The warning mentions the possibility of delayed-onset heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia and thrombosis (HITT).
Recommendation: Patients presenting with thrombocytopenia or thrombosis after discontinuation of heparin should be evaluated for HIT and HITT.

Digoxin order entry error perpetuated by robot (25)
Problem: A pharmacist incorrectly entered an order for 0.06 mg of oral digoxin as 0.625 mg daily; a dispensing robot filled the prescription using 5 tablets of the 0.125 mg strength. The patient received several doses and was transferred to ICU when the error was recognized.
Recommendation: Although oral digoxin is not typically a high-alert medication, consider programming the pharmacy computer system with a maximum dose alert. Encourage verification of all orders that require the use or administration of more than three dosage units of medication. Digoxin should be prescribed and entered into the pharmacy computer in mcg, not mg.

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.

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

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