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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - January and March 2007

From the April 19, 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! between January and March 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. Many product-related problems can also 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.

Key: v  — ISMP high-alert medication

vAnticoagulant safety takes center stage in 2007(1)
Problem:When used or omitted in error, anticoagulants including unfractionated heparin, low-molecular weight heparin, and warfarin, can cause life-threatening or fatal bleeding or thrombosis. Common risks associated with anticoagulants include: duplicate or concurrent therapy, calculation and dosing errors, look-alike vials or syringes, therapy omissions, and drug and food interactions.
Recommendation: Conduct an interdisciplinary FMEA to identify organization-specific sources of risk with the use of anticoagulants, and to individualize improvements needed to reduce the risk of errors. ISMP has created a sample FMEA, which can be found at: FMEAofAnticoagulants.pdf. Additional safety improvements can be found at: Newsletters/acutecare/articles/20070111.asp.

Danger in giving topical thrombin intravascularly (3)
Problem:Inadvertent intravascular injection of topical thrombin used on bleeding surfaces for hemostasis has caused fatalities in several instances. The product is provided as a powder for reconstitution in a vial, which can be mistaken as a parenteral drug. The drug is also packaged with a syringe to ease preparation and withdrawal.
Recommendation: Label syringes containing thrombin, “For topical use only–do not inject.” Have pharmacy prepare and label the drug when possible. Always communicate its presence when placing it on the sterile field. If possible, delay placement on the sterile field until after parenteral drugs have all been administered. Use of a spray kit, which requires attaching a spray tip to a syringe or a spray pump to a vial, may also help prevent errors. Vials of thrombin should never be placed at the bedside for reconstitution by staff.

vNew KADIAN (morphine sulfate extended-release) 200 mg strength could be confused with existing 20 mg strength (5)
Problem:FDA has approved Kadian 200 mg capsules. The product is also available in 20 mg capsules. A word of caution is in order since confusion has been reported between drugs that have a ten-fold difference in strength.
Recommendation: Precautions should be taken before making the higher strength of Kadian available for use. Remind prescribers that using a terminal zero when ordering the 20 mg strength of morphine is dangerous since 20.0 mg could be misread as 200 mg.

vDon’t abbreviate drug names (2)
Problem:Mycophenolate mofetil (CELLCEPT) was prescribed using an abbreviation, “MMF    1,000 mg po BID.” The physician also wrote out the name of the drug below this entry. A pharmacist and nurse misinterpreted the “MMF” as M-W-F, or every Monday, Wednesday, and Friday.
Recommendation: Unauthorized abbreviations of ANY drug name are potentially dangerous. Limit utilization of drug name abbreviations for drug combinations with very lengthy nonproprietary names. ISMP has recommended adding drug name abbreviations to The Joint Commission’s “Do Not Use” list for National Patient Safety Goal 2B.

“e-Rx” errors in the drug selection process (2)
Problem:Electronic prescribing (e-Rx) errors have occurred when prescribers inadvertently chose the wrong item from a drug selection database. For example, an error was reported in which a physician accidentally selected U-500 instead of U-100 insulin from a “drop down” box.
Recommendation: Build alerts and hard stops into electronic prescribing systems to warn users about potential prescribing errors (e.g., hard stop for required verification of all U-500 insulin orders). If you work in an environment that handles “e-Rx,” please consider sharing with ISMP any types of errors encountered.

Don’t miss important computer alerts (3,4)
In some settings pharmacy technicians or interns may enter prescriptions and medication orders into the pharmacy computer. A safety concern exists as pharmacists may not know about alerts that were displayed during the entry process and bypassed. Also, design flaws in existing entry systems often lead to mistrust in alerts and make the practice of quickly bypassing them seem acceptable.
Recommendation: To curtail an abundance of alerts, consider reducing the sensitivity of the computer alert system. Identify conditions that signal the most serious potential adverse drug events (e.g., drug-drug interactions) and use the list to customize priority alerts. Print a daily report of bypassed alerts for a pharmacist to review. If technicians are entering orders, print alerts on labels, or print the actual warning screen, to allow the pharmacist to review the bypassed alert during the final checking process.

vU-500 insulin errors (3)
Accidental selection of U-500 instead of U-100 insulin during electronic prescribing could lead to serious errors if not detected before administration of the drug.
Recommendation: One hospital reported that it flags all U-500 orders during the prescribing process, alerting the prescriber to the need for a consult by an endocrinologist. If U-500 insulin is still requested, the system takes the prescriber to an endocrine consult order screen. The endocrine team either approves the order, or notifies the prescriber if a concern exists.

vReducing patient harm from opiates (4)
Errors with opiates have led to serious adverse events, including allergic reactions, failure to control pain, over-sedation, respiratory depression, seizures, and death. Error-related risks include: look-alike drug names and packaging, mislabeled syringes, dose and concentration errors, lack of patient monitoring, and use of dangerous abbreviations.
Recommendation: To reduce the risk of patient harm, dispense concentrated oral liquid opiates from the pharmacy if required for a specific patient; provide equianalgesic charts for oral-to-IV conversions for practitioners; establish protocols for sedation and pain management; and label the distal ends of access lines to distinguish from epidural lines. Additional safety improvements can be found at:

Purchasing for safety (4)
To prevent mix-ups between look-alike products manufactured by the same company, hospitals may purchase one of the products from a different manufacturer. This safeguard may be met with resistance in the face of binding contracts with a manufacturer, purchasing group, or hospital purchasing department.
Recommendation: Purchasing decisions must always be made with patient safety in mind and not totally dependent on purchasing agreements. Pharmacy directors should seek the input of staff who will be using the product and gain approval from the Pharm-acy and Therapeutics Committee when making decisions about which brand to purchase. Clauses should appear in purchasing agreements to allow for changes if safety is an issue.

vLANTUS (insulin glargine [rDNA origin]) dosing error (5)
An order for “Lantus 8 Units” was almost misread as “80 Units” because the physician did not leave enough space in between the “8” and “Units” (8Units). The pharmacist had access to the patient’s previous admission history and was able to clarify the dose as “8 Units.”
Recommendation: Availability and review of patient information from prior admissions at the time of prescribing, dispensing, and administration is important to prevent medication errors. Prescribers should leave an appropriate space between the numerical dose and the measure of units.

ZYRTEC (cetirizine) and ZYPREXA (olanzapine) mix-ups (1)
Mix-ups have occurred between Zyrtec and Zyprexa, most often when orders and container labels have been misread. Both drugs are available in 5 mg and 10 mg tablet strengths, increasing the risk of confusion. Patients who have received Zyprexa in error have experienced  dizziness, and patients on Zyprexa for a behavioral health illness have relapsed when given Zyrtec in error.
Recommendation: Notify practitioners about the risk of mix-ups when either of these drugs are prescribed. Include the purpose of the drug on prescriptions. Store the containers of these products apart from one another, and add reminders on containers and computer screens about the potential for error.

Confusion in the CDC’s HIV post-exposure prophylaxis (PEP) guideline (5)
KALETRA (lopinavir/ritonavir) dosing in the CDC post-exposure prophylaxis (PEP) guideline for HIV is listed as “400/100 = 3 capsules bid.” This could be interpreted as 3 tablets of a 400/100 strength (which does not exist) or 6 tablets of the available 200/50 mg strength (total of 1,200/300 per dose). The guideline is actually referring to 3 capsules of a 133/33 strength, which is no longer manufactured in the US.
Recommendation: Confirm that your facility guidelines for PEP list only the dose (400/100) of Kaletra, not the number of tablets needed.

Safe practices not evident when dispensing drug samples (5)
A study that evaluated seven specific ISMP recommendations regarding safe dispensing of drug samples found that none of the 17 primary care practices participating in the study were compliant with all recommendations. Patients were usually given verbal instructions about the appropriate use of samples and side effects; however, labeling and written patient instructions were inadequate, which may increase the risk of medication errors.
Recommendation: The following information should be communicated on attached labeling of sample medications: patient name, reason for the medication, amount that should be taken, frequency of taking the medication, special precautions, and any significant side effects. If a medication requires reconstitution, the amount of water to be added should be described on the label. Additional recommendations for safe handling of samples can be found at:

v“Dilaudid” favored over “hydromorphone”  (6)
Problem: Root causes of mix-ups between hydromorphone and morphine include look-alike unit-dose packaging, name similarity, and prescribers who believe that dosing of the drugs is similar on a mg for mg basis.
Recommendation: One pharmacist reported that his hospital has eliminated the use of the name “hydromorphone” and is using ONLY the brand name “Dilaudid” on labels and in storage areas, formulary listings, computer selection screens, and computer-generated medication administration records. No mix-ups have been reported since then.

vPropofol and ROTAGLIDE look-alike vials (6)
Problem: When preparing to sedate a patient with propofol, an anesthesiologist noticed significant resistance when he attempted to withdraw the drug into a syringe. When he inspected the vial, he saw that it actually contained Rotaglide, a lipid-based emulsion used for lubrication in various surgical procedures.
Recommendation: Even if storage of these vials is segregated, mix-ups could still occur if the vials are in close proximity after removal for use. Vials should never be placed on the same work surface during a procedure, and Rotaglide should not be available until the induction of anesthesia has been completed.

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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