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ISMP Quarterly Action Agenda - october - december 2012

From the January 24, 2013 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 2012 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 Microsoft 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 at: Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

vPotential mix-up between NOVOLOG (insulin aspart) and NIMBEX (cisatracurium) (22)
Problem: In an emergency department, a pharmacist found a carton of NovoLOG insulin in a refrigerator bin where Nimbex cartons were stored. Both have very similar-looking packaging. A mix-up either way could be fatal.
Recommendation: In the pharmacy and clinical areas where neuromuscular blockers are necessary, segregate their storage in a sealed container, lidded bin, or intubation kit. Affix a warning label stating: Warning: Paralyzing Agent—Causes Respiratory Arrest. When the drug is no longer needed, place any leftover vials, bags, and syringes of these drugs in a sequestered bin for immediate pharmacy removal. 

vInsulin concentration rarely needed on orders (24)
Problem: On a medication reconciliation form, the U-100 strength for LANTUS (insulin glargine) was listed instead of the dose under the “dosage” section. This could be mistaken as an insulin dose of 100 units.
Recommendation: Do not include the U-100 concentration with typical insulin orders. The strength should only be listed parenthetically with doses of U-500 insulin. Educate staff to be suspicious of an insulin dose that is exactly 100 units and to verify its accuracy.

vImportant change with heparin labels (24,25)
Problem: The US Food and Drug Administration (FDA) announced that, effective May 1, 2013, heparin vial labels must express the strength per the entire container followed by the strength per mL in parentheses (50,000 units/10 mL). In the past, the strength was labeled only on a per mL basis (5,000 units/mL), with the volume of the vial appearing in a different location. Staff have mistaken the per mL strength as the total dose contained in a vial, which has led to heparin overdoses.
Recommendation: There will be a transition period where both labeling styles will be on the market. To minimize the potential for medication errors, purchasers and pharmacy managers should strongly consider separating the supplies of “current” and “revised” heparin, and using all of the “current” heparin before using products with the “revised” label.

 v Mix-ups between various formulations of amphotericin B (21)
Problem: Mix-ups have occurred between liposomal and conventional formulations of IV amphotericin B. Conventional amphotericin B doses should not exceed 1.5 mg/kg/day. Doses of the lipid-based products are higher. Harm, even death, may result if a mix-up between the two products occurs.
Reccomendation:Communicate orders using both the proprietary and complete generic name (e.g., AMBISOME [amphotericin B liposomal]), and include the reason for use, the patient’s weight in kg, the mg per kg dose, and the final dosage calculation. Restrict the preparation and dispensing of amphotericin B to the pharmacy. Dose checking alerts should be utilized in computer systems for both liposomal and conventional formulations. Consider adding a warning to storage areas of the conventional form to “question all doses over 50 mg.”

vARIXTRA (fondaparinux sodium) and ARISTA AH mix-ups (21)
Problem: A pharmacy received a request for “Aristra” from the operating room (OR). Arixtra, a Factor Xa Inhibitor, was dispensed, but the surgeon wanted Arista AH, a synthetic, absorbable hemostatic agent. Arista AH could not be found in Micromedex because it is a device, a factor that contributed to confusion. Name similarity went unnoticed during FDA approval because the products were evaluated by two different Centers within the agency.
Recommendation: While Arixtra might be used postoperatively in prevention of venous thromboembolic events (VTE) in adults undergoing certain types of surgery, it isn’t started until 6 hours after the procedure. Therefore, OR requests for Arixtra should raise suspicion and require verification.

Sterile compounding tragedy should spur assessment and action in hospitals (21, 22, 24)
The recent outbreak of fungal meningitis cases caused by contaminated steroid injections from a compounding pharmacy has led to scrutiny in these facilities. The outbreak should also lead hospitals to assess their own internal sterile compounding practices. A recent study has shown an overall contamination rate of 18.2% from fingertip testing, along with a 5.1% contamination rate of the compounded items. Only 13% of pharmacy school deans feel their students have been adequately trained in sterile compounding prior to graduation.
Recommendation: Use commercially available, ready-to-use, FDA-approved products from pharmaceutical manufacturers when possible. For medically necessary products that are not commercially available, carefully select and utilize a compounding pharmacy ( or internally compound the products. Tools are available to help assess and train staff in sterile compounding (,, including ISMP’s Guidelines for Safe Preparation of Sterile Compounds ( Establish a surveillance team to regularly test compounded preparations and monitor for compliance with USP <797>.

Distractions and interruptions contribute to medication errors (24)
Clinical staff are interrupted as often as once every 2-5 minutes. With nurses, error risk increases 12.7% with each interruption and is doubled if interrupted 4 times during a single drug administration and tripled when interrupted 6 times. Distractions and interruptions include anything that diverts attention away from the current task, forcing attention on a new task at least temporarily. Attending to the new task increases the risk of an error with both the prior task and new task because the stress of the distraction or interruption causes cognitive fatigue, which leads to omissions, mental slips or lapses, and mistakes.
Recommendation: Identify the sources of common interruptions and remedy any system issues such as frequently missing medications; untimely dispensing of medications; or frequent invalid, insignificant, or overly sensitive computer alerts and device alarms. Provide staff with a quiet area/no interruption zone with a dedicated medication room or a cordoned off area in which to select and prepare medications. Avoid placement of automated dispensing cabinets in hallways or busy nurses’ stations. Ask all staff to avoid interrupting other staff members during critical medication tasks.

New tools on safe injection practices (25)
The Centers for Disease Control and Prevention (CDC) has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors. Lack of initial and continued infection control training, denial of the problem, drug shortages, and lack of appreciation for the consequences of unsafe injection practices have all been at the root of these outbreaks.
Recommendation:  The CDC and the Safe Injection Practices Coalition (SIPC) released a suite of new materials to help healthcare providers learn about and follow safe injection practices ( The tools include PowerPoint slides, videos, podcasts, posters, and a press release kit. Healthcare facilities are encouraged to use the new tools.

vTeaspoonful—mL mix-ups with midazolam (VERSED) syrup (22)
ISMP has received more than 50 reports of mL-teaspoonful mix-ups. In the latest event, a nurse preparing a 2 mg dose of midazolam syrup measured out 1 teaspoonful instead of 1 mL. The BD oral syringe she used had both teaspoonful and mL scales. Oral syringes with a mL-only scale are currently not available in 5 mL and larger sizes.
Recommendation: ISMP has called for limiting the units of measure to only the metric system for devices, computer screens, medication orders, and dosing instructions on labels. Evaluate the oral liquid dosing devices used in your facility, and alert staff to the risk of measuring errors if both scales are on the syringe barrel. ISMP has asked manufacturers of dosing cups and oral syringes to make available mL-only devices for hospital use. 

Name mix-ups with cloBAZam (ONFI) and clonazePAM (KLONOPIN) (23)
Name similarity between clobazam and clonazePAM has led to several reports about the potential for confusion. The drugs share some similar indications (e.g., Lennox-Gastaut Syndrome) although they have a 10-fold strength difference in available dosage forms.
Recommendation: ISMP will be adding the pair of clobazam and clonazePAM to our List of Confused Drug Names and adding cloBAZam to our List of Look-Alike Drug Names with Recommended Tall Man Letters in future revisions. Ensure that this pair of medications has appropriate safeguards for differentiation at your institution.

Topical analgesics and burns (20)
Certain over-the-counter (OTC) topical products used for muscle and joint pain have caused rare cases of first- to third-degree chemical burns. These OTC products, including Icy Hot, Bengay, Capzasin, Flexall, and Metholatum, generally contain menthol, methyl salicylate, or capsaicin.
Recommendation:  Alert patients to the risk, and advise them to use these products exactly as stated on the label and to discontinue use if they feel actual pain (rather than a warming sensation) after applying them. Additional strategies can be found at:

USP Prescription Container Labeling standard (21)
The United States Pharmacopeia (USP) has created a webpage on outpatient prescription container labeling (General Chapter <17>) to guide organizations in the presentation of information in a patient-centered manner.
Recommendation:  If your hospital provides outpatient prescription services to patients and/or staff, assess current labeling procedures to ensure they match the guidelines (

Reduce readmissions with pharmacy community liaison program and patient education (20,23)
Medicare is fining hospitals with high readmission rates for three conditions—heart failure, myocardial infarction, and pneumonia. Studies have identified that adverse drug events (ADEs) are at the very core of readmissions. One recent study found that warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents account for 7 in 10 emergency hospitalizations among seniors. Another study found that patients with medication discrepancies had a 30-day readmission rate of 14.3% compared to 6.1% for patients without a discrepancy.
Recommendation:  External programs offered by community pharmacies as well as hospital-run community liaison programs can help hospitals reach their readmissions goals and decrease preventable ADEs. These programs provide in-home or telephone support of pharmaceutical care for recently discharged patients. Before and after discharge, education should focus on patients who are prescribed a high-alert medication, especially warfarin, insulin, antiplatelet agents, and hypoglycemic agents. ISMP offers free patient handouts for several of these high-alert medications to help prevent errors and other ADEs with these drugs (


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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