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ISMP Quarterly Action Agenda - october - december 2010

From the January 27, 2011 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 items from the October-December 2010 ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number 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 the ISMP List of High-Alert Medications. 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.

Key: v  — ISMP high-alert medication

Managing drug shortages (20)
Problem: Drug shortages take an enormous toll on healthcare providers who must deal with the problem on a daily basis, and on patients who are on the receiving end of the shortages. Although it may be impractical to prepare for every potential drug shortage, proper planning can minimize the adverse effects on patients and providers.
Recommendation:  Identify a person/team to identify drug shortages by reviewing the ASHP and FDA websites and communicating with other hospital purchasers. Once a shortage has been identified, assess current inventory, identify and approve therapeutic alternatives, tailor the drug’s use to priority patients for whom an alternative may be unsafe, and conduct a failure mode and effects analysis to identify process changes and potential misuses of alternative products. Keep staff updated on shortages and how they will be addressed.

Infection control practices with needles, syringes, and vials needs stepped-up monitoring (24)
Problem: A recent online survey of 5,446 nurses revealed an alarming lapse in basic infection control practices, including: reuse of a syringe for another patient after only changing the needle, reuse of single-use vials for multiple patients, reentry into a multiple-dose vial with the same needle/syringe, and use of a common bag or bottle from which to prepare IV flush solutions or drug dilutions. These practices place patients at risk for transmission of blood borne diseases.
Recommendation:  Enhance surveillance of proper technique and devote resources to ensure staff knowledge and skills associated with concepts of infection control and injection safety. Use prefilled syringes or single-dose vials when possible to reduce the risk of contamination. Inexpensive drugs should be provided in single-use containers and discarded after first use. Do not use bags or bottles of IV solutions as a communal supply of flushes for multiple patients.

v New Isotope Dilution Mass Spectrometry (IDMS) may affect CARBOplatin dosing (21)
Problem: All US clinical laboratories are now using a new standardized IDMS method to measure serum creatinine. The IDMS method appears to underestimate serum creatinine values, resulting in an overestimation of the glomerular filtration rate (GFR) and the potential for CARBOplatin-related dosing errors or toxicity.
Recommendation: To avoid potential toxicity, cap the dose of CARBOplatin for desired exposure (area under the curve [AUC]) if a patient’s GFR is estimated based on serum creatinine measurements using the IDMS method. Specific recommendations appear on the FDA website at: Offices/CDER/ucm228974.htm.

 v New TAXOTERE (DOCEtaxel) concentration and preparation (21, 23)
Problem:Taxotere now comes in a new one-vial double concentration formulation, replacing the previous two-vial (active drug and diluent) Taxotere packaging. The new one-vial concentration is 20 mg/mL compared to the previous two-vial preparation, which was 10 mg/mL. A forthcoming one-vial generic DOCEtaxel product (Hospira) will be provided in a 10 mg/mL concentration, the same as the previous Taxotere formulation but different than the new formulation.
Reccomendation:Alert all pharmacy and oncology nursing staff to the new formulation in a double concentration (20 mg/mL) and the forthcoming generic product that will be available in the prior concentration (10 mg/mL). Update computer system databases and internal drug resources to ensure proper mixing. If your computer system allows for order replication from past admissions, work with your IT department to intercept orders where medications have changed strengths. For additional information, visit:

Accidental IV administration of Dakin’s (diluted sodium hypochlorite) solution (21)
Problem: A woman admitted to a hospital with burns on her arm had orders for topical wound irrigation with Dakin’s solution. An IV was started in the same arm and later capped but not removed because it was partially covered by the burn dressing. The nurse believed the capped IV was an irrigation catheter under the dressing and administered the Dakin’s solution via the capped IV catheter.
Recommendation:  Apply clearly visible labels on access lines that are covered with dressings or clothing. Trace tubing and catheters to the point of origin to prevent misconnections. Ask vendors to supply a setup for irrigations that won’t connect to an IV access port (e.g., Hospira sterile water for irrigation bottle with a screw cap and an irrigation administration set). When possible, prepare irrigations in the pharmacy in containers that are dissimilar to IV containers.

vConfusion between Hospira’s HYDROmorphone and ePHEDrine  (20)
 A pharmacist caught an error in which Hospira’s HYDROmorphone 4 mg ampuls had been pulled for unit stock instead of the intended ePHEDrine sulfate 50 mg ampuls. The yellow and white labels and cartons for both products look very similar.
Recommendation: Consider purchasing one of the products from a different manufacturer. Barcode scanning and independent checks by at least two pharmacy staff—which led to error detection in this case—are also measures to prevent mix-ups.

Improving compliance with the use of smart infusion pump libraries (20)
During a 3-year study on smart pumps, overall use of safety software rose from 33% in November 2006 to over 98% by December 2009 (Breland BD. Continuous quality improvement using intelligent infusion pump data analysis. Am J Health-Syst Pharm. 2010; 67:1446-1455). Many clinically significant dosing errors were intercepted and corrected by the safety software.
Recommendation: Share the published article with your continuous quality improvement (CQI) team, pharmacy and therapeutics committee, and hospital administration if you are struggling to improve compliance with the use of smart pump drug libraries.

ISMP updates list of look-alike drug names with recommended TALL man letters (23, 25)
Drug names that appear to be very similar when handwritten and/or typewritten (e.g., computer screens, typed labels) have a high potential of being confused, leading to drug prescribing, dispensing, and administration errors. Difficulties with the use of tall man letters, which can help distinguish look-alike names, include inconsistent application in health settings and lack of standardization regarding which name pairs to include as well as which letters to present in uppercase.
Recommendation:  Highlighting a unique portion of a drug name by using “tall man” lettering draws attention to the dissimilarities of look-alike drug names. Following a recent survey, ISMP updated its list of drug name sets with tall man letters using a standard method for selecting which letters should be capitalized. Use the tall man lettering scheme provided in this list ( to promote consistency.

Thumb can still be injected despite EpiPen (Dey Pharma) redesign (22)
A nurse unfamiliar with the new design of the EpiPen accidentally injected her thumb by pushing on the wrong end (orange tip) of the pen, presuming that it was similar to the NOVOLOG (insulin aspart) FLEXPEN, which has an orange button to inject the insulin. While injecting EPINEPHrine into a thumb or finger may cause restricted tissue perfusion, the greater risk is to the patient if EPINEPHrine administration is delayed.
Recommendation:  Provide healthcare professionals and patients with instructions on the proper use of an EpiPen (visit: Incorporate a return demonstration by the healthcare professional and/or patient to ensure understanding of the procedure and skill when performing the required injection.

CATAPRES-TTS (cloNIDine transdermal therapeutic system) adhesive cover applied without drug patch (22)
 Catapres-TTS is packaged with an optional white, round adhesive cover to use over the patch in case it comes loose. ISMP received several reports in which just the cover was applied to the patient without the patch containing cloNIDine. One patient at a long-term care facility did not receive clonidine for 2 weeks because only the cover was applied.
Recommendation:  Have pharmacy dispense each patch/cover pair in a plastic bag with a label reminder to apply the medication patch and adhesive cover. If applying the white patch cover over the tan medication patch, label the cover before application with the drug name and strength, and leave a small edge of the medication patch uncovered to identify that the medication patch is underneath.

Nasal calcitonin-salmon confused with injectable product (24)
A physician prescribed IM calcitonin-salmon, but the pharmacy dispensed a vial of the nasal formulation without the nasal applicator. A nurse failed to recognize that the incorrect formulation was dispensed and attempted to get an IM dose from the vial by inserting a needle through the stopper.
Recommendation:  Never dispense the nasal formulation without sending the accompanying spray applicator. If possible, order FORTICAL nasal spray rather than the generic product. Fortical is manufactured with a simple twist-off style cap, and the vial is less easily confused with the injectable formulation.

Confusing Sandoz itraconazole packaging (21)
 The itraconazole “100 mg” capsule strip pack actually contains two 100 mg capsules. Staff may believe that the two capsules together equal 100 mg, which can lead to dosing errors.
Recommendation:  To prevent confusion, label this product as itraconazole 200 mg (2 x 100 mg capsules). If you supply unit dose products to nursing homes or other outpatient settings, you may want to note this on the medication administration record or repackage the product.

Metallic content of drug patches and magnetic resonance imaging (MRI) (23, 25)
Serious burns may occur in patients undergoing MRI who are wearing transdermal patches that contain metal. The metal acts as a conductor of radiofrequency pulses, inducing electric current.
Recommendation:  Instruct all patients who use transdermal patches to notify staff when they are about to undergo any testing such as MRI. Obtain the latest review (here) on metal in drug patches, which provides information related to the metallic content of available transdermal patches and the recommendations regarding reapplication of transdermal therapy after a scan.

Document using military not conventional time  (20)
When conventional time (using a.m. and p.m. designations) is used to time orders and medication entries, confusion may arise regarding whether “midnight” means the very end of the day or the very beginning of the next day.
Recommendation: ISMP suggests standard utilization of military time in hospital settings for all documentation of time to avoid any potential confusion. 

Super glue (cyanoacrylate) mixed up with eye medications  (25)
A woman who had had cataract surgery was reaching for her eye medications when she mistook Super Glue for eye ointment and glued her eye shut.
Recommendation: In the event that eyelids are stuck together or bonded to the eyeball, Super Glue Corporation recommends that you wash the area thoroughly with warm water and apply a gauze patch. The eye will open without further action within 1-4 days. Individuals using ophthalmics should be warned not to purchase Super Glue in a container that looks like an eye medication, and they should store the glue far away from all medications.


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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