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ISMP Quarterly Action Agenda - october - december 2011

From the January 26, 2012 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 2011 issues of the 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’s 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. Many product-related problems can also be viewed in the ISMP Medication Safety Alert! section of our website. Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

Centers for Medicare & Medicaid Services (CMS) revises its policy on the “30-minute rule” (24)
Problem:The CMS interpretive guidelines that required all scheduled medications to be administered within 30 minutes has led to unsafe practices and errors. Nurses often felt pressured to take potentially dangerous shortcuts to comply, which sometimes led to errors, some harmful. In many cases, administering scheduled medications within 30 minutes is unnecessary from a clinical perspective.
Recommendation: CMS has eliminated the requirement that all scheduled medications must be administered within 30 minutes of their scheduled time ( Hospitals are expected to establish their own policies for the timing of medication administration that appropriately balances patient safety with the need for flexibility in work processes. ISMP guidelines to assist with this can be found at:

vUS Food and Drug Administration (FDA) approves HYDROmorphone labeling revisions and lower starting dose (21)
Problem: FDA and ISMP have received reports of harmful errors involving HYDROmorphone injection. Many have been associated with dose conversions from morphine to HYDROmorphone, packaging confusion, and high starting doses for opioid-naïve patients.  
Recommendation: FDA approved revisions to the Prescribing Information ( scription/DilaudidInjectionsPI.pdf), container labels, and carton labeling for DILAUDID and DILAUDID-HP, which will also affect generic parenteral HYDROmorphone. Alert prescribers that the IV starting dose has been reduced to 0.2-1 mg (previously 1-2 mg), and that a dose conversion table is in the Prescribing Information to help convert from other opioids to HYDROmorphone. 

Differences in trace elements (21)
Problem: During a shortage of American Regent’s pediatric trace elements (Trace Elements Injection 4, USP-Pediatric) in 10 mL multiple-dose vials, the pharmacy ordered the company’s MULTI-TRACE-4 PEDIATRIC in 3 mL single-dose vials. Both products are labeled as Trace Elements Injection 4, USP, but the 3 mL vial has 0.5 mg more zinc and 5 mcg less manganese per mL.
Recommendation: When you order and receive new or alternative products due to drug shortages, check that the products are equivalent to previously used products. 

 v FentaNYL and SUFentanil mix-ups (23)
Problem: With the current shortage of fentaNYL, some hospitals may resort to using SUFentanil. Serious dosing mix-ups are possible in situations where people using SUFentanil instead of fentaNYL are not familiar with the differences between these drugs. The risk of confusion is high because both drugs are potent analgesic/anesthetic products with similar generic names. Such mix-ups happened in 2001 during a similar fentaNYL shortage.
Reccomendation: Since SUFentanil is approximately 10 times more potent than fentaNYL, educate staff about the difference in potency and include visual reminders wherever the drug is stored. Design mnemonics for these products carefully, and avoid the use of “su” alone to select the medication since the brands SUFENTA (SUFentanil) and SUBLIMAZE (fentaNYL) may come up on the pick list. A check system should be in place prior to administering such potent opioids.

vSafety issues with “ketofol” (combination of ketamine [KETALAR] and propofol [DIPROVAN])  (21)
Problem: While studies show that “ketofol” may be effective and safe for procedural sedation, some concerns linger. Admixture often occurs on units where sterility may be difficult to maintain; practitioners may be unfamiliar with the contrived name and not find it in any reference; little information is available regarding compatibility with other drugs; ratios for combining the two drugs varies; and a syringe containing “ketofol” looks like a syringe containing just propofol.
Recommendation: Conduct a failure mode and effects analysis to assess risks before using this combination product. Take steps to promote sterility during admixture. Establish a standard ratio to guide the mixing process. Refer to the product using each drug’s official name, not “ketofol.” Include both drug names and an expiration date on syringes of the product. An article detailing the use of “ketofol” was published recently (Thomas MC, et al. Combination of ketamine and propofol versus either agent alone for procedural sedation in the emergency department. AJHP. 2011;68:2248-56). 

Conservative prescribing needed to improve medication safety (23)
 Wrong drug errors often arise when medications are prescribed inappropriately or overused, sometimes leading to significant harm. These errors suggest that an important facet of medication safety is making sure the right drug is prescribed only when indicated. In the September 2011 issue of the Archives of Internal Medicine, Schiff and colleagues provided a set of principles to guide more conservative prescribing of medications intended to help ensure that patients receive the right drug only when indicated.
Recommendation: To instill more thoughtful, evidence-based prescribing attitudes and behaviors, the authors identified the following principles: (1) Think beyond drugs—focus on disease prevention and consideration of underlying causes of conditions before prescribing a medication; (2) Practice more strategic prescribing—use a limited personal formulary of drugs so that familiarity with dosing, adverse effects, drug interactions, etc., is increased; (3) Exercise caution and skepticism regarding new drugs—avoid the rush to prescribe; wait for evidence of actual beneficial clinical outcomes.

Infant acetaminophen available in new concentration (23,24)
The new 160 mg/5 mL infants’ acetaminophen concentration has been arriving in hospitals, although manufacturers may not be providing notification about the change. Supplies of the former 80 mg/0.8 mL product have been available up until now, and hospitals (and parents) may still have the older concentration in stock. Some acetaminophen products do not have the new strength listed on the front panel of the carton.
Recommendation: Exhaust or remove all supplies of the 80 mg/0.8 mL product before circulating the new one. Alert all clinical staff, especially pediatricians and pediatric nurses, to create awareness of the concentration change and establish a release date for transition from the older product to the newer product. Also be certain that parents understand how many mg to give their child and that they have the new product that corresponds to instructions from their healthcare provider. 

ISMP issues statement on use of metric measurements (24)
ISMP first reported confusion between teaspoonfuls and mL in 2000. In 2009, we called for practitioners to move to sole use of the metric system for measuring oral liquid medication doses. How-ever, ISMP continues to receive reports of mL-teaspoonful mix-ups, some resulting in hospitalization. Mistakes have also been reported when converting weights from pounds to kg or weighing a patient in pounds and entering it as kg. 
Recommendation:  Use only metric units for all dosing instructions, including directions incorporated in prescribing and pharmacy computer systems. Express doses for oral liquids using only metric weight and volume. Measure and express patients’ weights in kilograms. Ensure patients have an appropriate measuring device and can demonstrate understanding regarding how to measure a dose of medication.

vDosing errors with LUGOL’S solution (potassium iodide and iodine)  (21)
Dosing errors associated with prescribing, dispensing, or administering mL doses of Lugol’s solution have occurred when just a few drops were indicated. Contributing factors include unfamiliarity with the drug, which is infrequently prescribed, and unexpected dosing units, as adult doses are typically expressed in mL, not drops.
Recommendation: Provide protocols for managing acute hyperthyroidism, protecting the thyroid during exposure to radioactive iodine, and preoperative use of iodine solutions. Include iodine solution dosing information in protocols and order entry systems. Dis-pense each dose of iodine solution in a prefilled syringe. If a bulk bottle must be dispensed, affix a warning: “The total volume in the container would be toxic if taken as a single dose.”

Differentiating penicillin from penicillAMINE (CUPRIMINE) (20)
An electronic prescription for the chelating agent penicillamine was ordered for a young boy, but the prescriber intended to order penicillin. The drugs have similar names and appeared sequentially on the order entry screen.  
Recommendation: Consider using tall man letters for penicill-AMINE on order entry screens, labels, shelf talkers, medication administration records, and other media for communicating the drug name. Incorporate the brand name and the purpose of the medication on the prescription.

Ingestion or aspiration of foreign objects or toxic substances (22)
A hospitalized surgical patient developed a postoperative cough that continued for a couple of weeks after discharge. During a strong coughing spell, the patient coughed up a small white cap. The patient had accidentally ingested or aspirated a 0.9 % sodium chloride syringe cap, which the hospital used for IV flushes. 
Recommendation:  Staff who enter patient care areas need to keep the patient’s room and/or immediate care area free of clutter that could result in accidental ingestion or inhalation of unin-tended products—even when patients are fully alert and oriented. Never leave syringe caps, fixatives, developer solutions, cleaning agents, topical antiseptics, or other topical liquid products at the bedside.

Replace child-resistant caps after measuring liquid doses using an oral syringe and adapter (25)
 In the home, adapters that fit on bottles of oral liquid medications make it easier for parents to withdraw the medication into an oral syringe. After use, some parents have left the adapter in the bottle rather than replacing the child-resistant safety cap. Children can access the liquid medication by easily removing the adapter, which has led to accidental poisonings that require hospitalization.
Recommendation:  Dispense oral liquid medications with an oral syringe adapter that allows the child-resistant bottle cap to be replaced without removing the adapter. Even with adult liquid medications, this precaution is critical to prevent a child from accessing adult medications. Join the Up and Away and Out of Sight Campaign (, and help remind consumers about safe medication storage.

Drug names that end with the letter “L” can contribute to overdoses (25)
Drug names that end with the letter “L” have occasionally contributed to overdoses. The lower case “l” has been misread as the numeral “1” and misread as part of the dose. For example, lisinopril 2.5 mg can be misread as lisinopril 12.5 mg if there is inadequate space between the last letter of the drug name and the numerical dose (i.e., lisinopril2.5 mg).
Recommendation:  Advise prescribers, pharmacists, and nurses to leave sufficient space between the numeric dose and the drug name. This recommendation also applies to electronic prescribing and standard order sets since typed drug names and doses can also result in errors if sufficient space is not provided between the drug name and dose/strength.

PCN-200 may be an erroneous choice when entering allergies to penicillin (21)
A discontinued nutritional supplement “PCN-200” may still be an option if “PCN” is typed when entering a penicillin allergy into the computer. If “PCN-200” is selected in error, no warning would appear if a penicillin order was entered for a penicillin-allergic patient.
Recommendation: If PCN-200 is still listed as an option when you enter “PCN” in your allergen pick list, remove it manually or work with your computer system vendor to remove it. Be sure to check all information systems where allergy entries may occur.

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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