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 - october - december 2007

From the January 31, 2008 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! between October and December 2007. 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! 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:

Key: v  — ISMP high-alert medication

vSerious threats still exist with potassium (20)
Problem:Reports of patient harm from inadvertent administration of concentrated potassium chloride continue to be received. The availability of concentrated potassium chloride in specialty areas, mix-ups between potassium products, and erroneous selection of concentrated potassium—especially when the pharmacy is closed—are commonly identified underlying problems
Recommendation:Maximize the use of premixed or commercially available potassium admixtures; ensure all potassium products are ordered via pharmacy; prohibit vials (even those labeled for individual patients) on nursing units; establish a discrete stock of potassium chloride solutions for after-hours use in a secured area; and develop an after-hours drug retrieval plan that does NOT require nursing personnel to enter the pharmacy. See the full article with additional recommendations at:

Pulmicort Flexhaler (budesonide inhalation powder) dose countdown misleading (20)
Problem:The numbers visible in the dose indicator window in Pulmicort Flexhaler provide confusing information to patients. The dial is labeled in increments of 20, and actual movement of the dose-counter may not be discernable. Patients may have difficulty telling if a dose has been received.
Recommendation: Patients who use Pulmicort Flexhaler should receive explicit instructions about the slow-moving design of the dose counter, how to actuate the device, and how to tell when the device is empty. The manufacturer will provide tear sheets and updated information on the Pulmicort Flexhaler website once FDA approves a revision of patient instructions.

Error-prone conditions that lead to student nurse-related errors (21)
Problem: Medication errors that involve student nurses may be fostered by unique circumstances arising when students, instructors, and nursing staff members partner to provide care. For example, patients assigned to both a student nurse and a staff nurse have received duplicate doses of medication if drug administration is not well coordinated.
Recommendation: Facilities that serve as clinical sites for student nurses should be aware of these circumstances and prevent errors by adopting proactive measures, which are described in the full article available at: care/articles/20071018.asp.

Read back and verify (21,24)
Problem:A poison control center reported a near-miss in which a drug antidote, fomepizole, was misheard by the treating physician as “omeprazole.” Another near-miss involving a sound-alike drug pair occurred when a community pharmacist receiving a telephone order misheard “Prograf” for “Prozac.” The error was intercepted when patient counseling occurred.
Recommendation: Adopt and utilize meticulous “read-back and verify” practices wherever verbal and telephone orders are received and whenever drug-related advice is given. Spell out drug names and include both the brand and generic names when both are known. Create another opportunity to catch downstream errors by educating patients when medications are dispensed and administered.

vColchicine deaths (21)
Problem: CDC has reported a series of deaths that occurred as a result of colchicine overdose.  Prescribing and compounding errors were identified in the analysis of three cases. Little evidence supports the use of IV colchicine for back pain yet the therapy remains popular among alternative healthcare providers.
Recommendation: Evaluate off-label use of this high-alert drug in your facility. Clinicians who prescribe, dispense, and administer colchicine for any indication should be aware that the maximum cumulative dose is 4 mg IV for a single course of therapy with a 7-day colchicine-free interval after each course.

Product-related issues make error potential enormous with investigational drugs (22)
Although many patients benefit by participating in investigational drug trials, routine practices used by the research-oriented pharmaceutical industry when naming, labeling and packaging the drugs, and by research organizations when storing and dispensing them, raise serious patient safety concerns.
Recommendation: Include a medication safety specialist on IRBs to ensure drug safety concerns are identified and resolved with research companies prior to protocol approval; use auxiliary labels to provide information missing from product packaging, especially when patients self-administer investigational drugs. For the complete article, visit /articles/20071101.asp.

vUnintended consequences of high-alert stickers (22)
A patient received an IV insulin infusion instead of the ordered fluconazole, resulting in profound hypoglycemia. Inadvertent omission of the “high alert” sticker usually placed on insulin infusions was identified as a proximate cause in the case. Without the sticker, the 100 mL bags looked similar, and the nurse, who was accustomed to high-alert stickers on insulin bags, picked up the wrong one and hung it.
Recommendation: Do not overuse auxiliary warning labels as this may cause practitioners to become de-sensitized to the message these warnings carry. Once an agent is designated to receive a high-alert label, a process to ensure consistent use of the label should be implemented.

Errors with injectable medications: Unlabeled syringes are surprisingly common! (23)
Unlabeled syringes are a significant risk associated with preparation of injectable products in clinical areas. The Joint Commission’s Medication Management standards prohibit this practice, but we regularly observe unlabeled syringes during hospital consults when we visit clinical areas. Barriers that prevent frontline nurses from labeling syringes must be identified and removed.
Recommendation: Whenever feasible, use commercially prepared syringes. Have pharmacy dispense medications in ready-to-use syringes, labeled for specific patients. When injectables must be prepared on patient care units, syringe labels must be available and put into use. Commercial syringes with write-on strips are also available. Promote consistency in label application and monitor compliance.

vPatient confused by insulin pen design (23)
Problem: A patient received a three-fold overdose of insulin (which resulted in an emergency department visit) when he misunderstood how to use the SoloStar insulin delivery device. Pen devices may not have features—such as the ability to see the plunger moving—that patients rely on to tell if a dose has been given.
Recommendation: Patient education is mandatory when insulin pen devices are prescribed, especially if patients are used to conventional syringes with plungers that move with each dose. Nurses and dispensing pharmacists should verify that the patient understands how to use the insulin pen. Observe a return demonstration to validate learning. An instructional video describing SoloStar use is available at

Ambiguous drug doses (23)
A patient discharged to a long-term care facility received double doses (400 mg) of Seroquel (quetiapine fumarate) because the discharge medication list ambiguously stated, “Seroquel 2 tablets = 200 mg, bid.” The inpatient facility used 100 mg tablets, but the long-term care facility used 200 mg tablets.
Recommendation: On discharge instructions, do not include information that translates dosing information into specific tablet strengths or volumes of liquids that have been used in the hospital. Only the drug name, dose, route of administration, and frequency should be included for each drug listed. If automated reports pull data from the MAR, be certain that product-specific dose prompts are removed.

Limit dose of topical benzocaine spray administered to mucous membranes (23)
Patients receiving topical benzocaine sprays to the mucous membranes can experience methemoglobinemia, an adverse drug reaction that may occur if the number and duration of sprays administered exceeds package insert guidelines.
Recommendation: Health professionals who work in settings where topical benzocaine products are used should be alert to the hazard. Provisions to obtain and infuse the antidote, methylene blue, should be in place in all settings where topical benzocaine is used.

vMethotrexate errors when treating ectopic pregnancy (24)
A physician prescribed methotrexate based upon mg/kg instead of mg/m2 dosing.  Significant patient harm was prevented when the on-duty pharmacist recognized the error and clarified the order before dispensing the drug. Methotrexate has caused severe toxicity when used to treat ectopic pregnancy in women with significant renal disease.
Recommendation: To catch prescribing errors involving the high-alert drug methotrexate, organizations should ensure that appropriate dose-checking features and warnings in CPOE and pharmacy computer systems are enabled. Pharmacists should verify doses and the absence of renal disease before dispensing this agent.

vAnother heparin error: learning from mistakes so we don’t repeat them (24,25)
Problem: Additional cases of heparin overdose in neonates have been reported. System failures in recent cases were remarkably similar to fatal events that were previously analyzed and reported, suggesting that leaders and clinicians do not fully utilize data reported by ISMP and others to reduce risk in their organizations. Reoccurring system failures appear to have included: erroneous placement of concentrated heparin (10,000 units/mL) in neonatal care areas; look-alike packaging; failed check systems; and confirmation bias.
Recommendation: Take proactive measures to prevent similar mishaps in your organization. To prevent heparin overdoses in neonates, review current literature related to the use of heparin to maintain patency of central lines; in pharmacy, use independent double-check systems or bar coding to verify all drugs before dispensing to unit ADCs; do the same on nursing units when withdrawing from ADCs; use commercially available heparin flush syringes or 10 units/mL vials that look distinctly different from more concentrated heparin vials.

Nitroglycerin overdoses (24)
Problem: Several cases of inadvertent nitroglycerin overdoses occurred when the contents of 25 tablet stock bottles were administered, instead of individual tablets. Stock bottle labels list a per-tablet dose, not a per-bottle dose, which may not be understood by nurses who do not regularly give medications from stock bottles.
Recommendation: Consider packaging the original amber glass bottle of nitroglycerin in a plastic bag or plastic amber vial, affix a label stating, “Each tablet contains nitroglycerin 0.4 mg.” Reinforce the adage “If you need more than 3, call the pharmacy.”

vAvoiding mix-ups between sterile water and sodium chloride bags (25)
Problem: When patients receive intravenous infusions of sterile water—instead of intended isotonic or nearly isotonic solutions—serious, even fatal, complications may occur. Factors that predispose these products to mix-ups include similarity in labeling, identical bag volumes, and storing these products in close proximity.
Recommendation: Take steps to prevent inadvertent IV administration of sterile water by segregating it in the pharmacy and labeling storage areas with a warning that it should never leave the pharmacy. Consider using only 2 liter bags of sterile water for injection, as this large size provides a visual cue for pharmacy and nursing personnel who might otherwise confuse products.

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