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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - January - March 2008

From the April 10, 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 January and March 2008. 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 the ISMP 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 nurses at:

Key: v  — ISMP high-alert medication

ADC survey shows some improvements, but unnecessary risks still exist (1)
Problem: Automated dispensing cabinets (ADCs) have the potential to improve efficiency, drug security, and charge capture. Although more facilities are adopting practice safeguards needed to ensure safety when using ADCs, an ISMP survey shows that an unacceptably high number of organizations remain vulnerable to serious errors stemming from ADC use.
Recommendation:Complete results of the ISMP survey can be found at: ISMP identifies 12 core processes needed for safe ADC use. Ensure that standard operating procedures for
ADCs in your organization incorporate these recommendations, available at:

vKeeping patients safe from iatrogenic methadone overdoses (3)
Problem:Patients being treated with methadone for narcotic addiction or chronic pain have received inadvertent, sometimes fatal, overdoses. In vivo, methadone behaves differently than other opiates, and these differences must be appreciated by healthcare professionals who prescribe, dispense, or administer methadone, and by the patients who receive the drug.
Recommendation: Methadone has been confused with dexmethylphenidate, methylphenidate, and MEPHYTON (phytonadione), so ensure appropriate look- and sound-alike safeguards are maximized. Other problems span the medication- use process. Patient screening should occur when use of this drug is contemplated. A complete list of risk-reduction strategies is available at:

vColchicine injection withdrawn from market (3)
Problem: Manufacturers of colchicine injection have been informed by FDA that the injectable product may no longer be manufactured, and shipping must stop within 6 months. Efficacy of injectable colchicine is unproven, and its narrow therapeutic margin has resulted in numerous
patient deaths.
Recommendation: Healthcare organizations should remove remaining colchicine injection from their inventory, drug formularies, and databases. Only colchicine tablets that also contain the active ingredient probenecid are approved for use. Colchicine tablets without probenecid remain on the market for now, but are not approved.

Daytrana patch shared among children (4)
Problem:A kindergarten student wearing a DAYTRANA patch (methylphenidate transdermal system) shared it with a peer who wore it for several hours. Daytrana’s consumer medication guide does not explicitly advise parents to counsel children not to share the patch with others.
Recommendation: Transdermal systems that deliver controlled substances to children require special handling and specific patient education in order to ensure safe use. Do not refer to transdermal drug systems as “band-aids,” “stickers,” or“tattoos.” Parents should be counseled to tell teachers and other caregivers if their children are wearing patches.

vNew look-alike name pair: Nexium and Nexavar (4)
Problem:NEXIUM (esomeprazole), a proton pump inhibitor, has been confused with NEXAVAR
(sorafenib), a chemotherapeutic agent identified as a high-alert drug. Confirmation bias led the pharmacist to misinterpret the less familiar product, Nexavar, as the more familiar Nexium.
Recommendation: Prevent this mix-up in your organization by using tall man lettering in computer systems and requiring prescribers to include the purpose of the drug on the order or prescription.

Resolving human conflicts when questions about the safety of medical orders arise (5)
Harmful prescribing errors are often questioned by another healthcare professional, a patient, or a family member, but the concerns may not be appropriately acted upon or addressed in a timely fashion. Intimidation and fear of confrontation have been identified as barriers to effective communication.
Recommendation: Strategies for resolving conflicts should be incorporated into organizational policies. Strategies can be found at: Expectations of prescribers when called about the safety of an order must be defined and incorporated into prescribers’ credentialing processes.

More support for bar-coding (5)
Bar-code technology benefits extend to laboratory specimens. ISMP and other safety organizations have asked The Joint Commission to consider adoption of a National Patient Safety Goal requiring organizations to begin initial evaluation of bar-coding technology if they have not already done so.
Recommendation: At a minimum, organizations should be investigating bar-coding system functions, meeting with vendors, considering costs, making budgetary projections, and understanding the infrastructure requirements needed to implement bar-coding. For a tool to help assess bar-coding readiness, visit:

vHespan and heparin bag mix-ups (5)
Look-alike cartons of B. Braun’s HESPAN (hetastarch) and heparin were confused, and large volume bags of heparin arrived in an anesthesia stock room under the mistaken assumption that they were Hespan. Ironically, B. Braun’s heparin had been purchased for the purpose of evaluating its look-alike potential with B. Braun’s hetastarch product.
Recommendation: Prevent mix-ups between heparin and hetastarch by: not storing heparin and Hespan alphabetically; labeling products, bins, and ADC storage areas with alerts reminding of the error-potential; referring to hetastarch products by the generic name;
and maximizing the ability of clinicians to visually distinguish these products from one another,
using different product vendors if necessary.

Pediatric gentamicin vials confused (5)
Preservative-containing gentamicin was administered intrathecally two times to the same pediatric patient. The error occurred when APP’s 2 mL multi-dose vial of gentamicin 20
mg/2 mL (containing preservatives) was confused with 2 mL single-use vials of gentamicin
20 mg/2 mL (preservative-free).
Recommendation: The vials had look-alike characteristics and multiple pharmacists made the same error. APP reports they are improving the label to call attention to the preservative status. In the meantime, affix bold labels to these vials to ensure that the product and its preservative status are readily apparent during dispensing and administration. Investigate the possibility of stocking only the preservative-free product.

vErrors with methotrexate associated with unit of measure on syringe (6)
PSome providers recommend using insulin syringes when patients self-administer methotrexate. Patients may misunderstand and miscommunicate dosing instructions, especially if they express doses in units instead of mg. Dosing confusion becomes commonplace anytime insulin syringes are used to administer any non-insulin product.
Recommendation: Teach patients how much medication to take using the unit of measure associated with the drug, not a volume or “unit equivalent” associated with a particular syringe. Clinicians must be sure to elicit and express methotrexate dosing information accurately, being aware that patients may express doses in atypical units of measure.

Fatal overdose uncovers need to rethink where pediatric IV medications are dispensed and administered (2)
A preschooler died following a medication error in an outpatient clinic that performed growth hormone stimulation testing using IV arginine. Dispensing and administration safeguards could have prevented the error or detected it at an earlier point. The parents expressed concerns about the dose and their child's response to the drug, but the error continued unnoticed.
Recommendation: Pediatric diagnostic testing and treatment using IV medication should occur only in dedicated infusion centers where standard protocols for these therapies are familiar to staff. IV medications should be dispensed in patient-specific doses and independently checked before administration. Halting therapy to thoroughly investigate
atypical responses should be the norm.

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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