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ISMP Quarterly Action Agenda - January - march 2013

From the April 18, 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 January-March 2013 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. Continuing education credit is available for nurses at:
Key:v   — ISMP high-alert medication


vNAN ALERT: KADCYLA (ado-trastuzumab emtansine) confused with HERCEPTIN (trastuzumab) (5,8)
Problem: Strong similarity between the generic names of Kadcyla (ado-trastuzumab emtansine) and Herceptin (trastuzumab) may result in harmful errors given differences in dosing and treatment schedules. Ado-trastuzumab emtansine may not be fully communicated or may be misread. Certain drug information references display the generic name of Kadcyla without the “ado” prefix, so those searching with this prefix may not find the drug, potentially resulting in the inability to prescribe it.
Recommendation: Alert practitioners to the risk of incomplete presentation of the generic name of Kadcyla in publications and information systems. Hospital computer systems and guidelines should employ strategies to differentiate the names and warn against confusion. Promote use of both the brand and full generic names when communicating orders on order sets or computerized prescriber order entry systems. For more information, view a recent National Alert Network (NAN) Alert at: nan.

vNAN ALERT: Remove “glacial” acetic acid from the pharmacy (2)
Problem:“Glacial” acetic acid (99.5%) has been accidentally purchased, dispensed, and/or applied topically during colposcopy and other procedures, such as wound irrigations, instead of a much more diluted acetic acid solution (0.25% solution, 2% solution [irrigation], vinegar [5%]). Severe pain, serious tissue damage, third-degree burns, and in one case, bilateral leg amputation have resulted.
Recommendation: ISMP has published an Alert ( nan) through the National Alert Network (NAN), which recommends removing glacial acetic acid from the pharmacy and replacing it with vinegar or a commercially available 0.25% or 2% solution. Conduct an independent double-check in the pharmacy to verify that the correct strength of acetic acid has been ordered and is dispensed.

vRemove multiple-dose pen devices from inpatient use (2,3)
Problem:Between 2010 and 2012, close to 7,000 patients may have been exposed to HIV, hepatitis B, or hepatitis C because insulin pens were reused for multiple patients after only changing the needle. Contamination from retrograde blood flow into the pen after injection is possible. Repeated warnings from FDA, ISMP, and CDC, along with staff education and monitoring, have not been successful in reducing these events.
Recommendation: Given reports of ongoing misuse of insulin pens—in particular, ISMP believes the risk associated with cross-contamination is best mitigated by giving consideration to removing insulin pens from use in hospitals. The Veterans Health Administration (VA) recently prohibited use of multiple-dose pen devices in VA facilities with a few exceptions ( ISMP urges other hospitals to follow suit. 

 v Safe use of insulin vials (4)
Problem: While ISMP stands behind its recommendation for hospitals to consider transitioning away from insulin pen use, simply replacing insulin pens with insulin vials may result in errors. Staff accustomed to using insulin pens may have knowledge deficits about withdrawing insulin doses from a vial. The U-100 designation on insulin vials has been misunderstood to mean 100 units per vial, leading to overdoses. The dose in units has been measured in mL by staff unfamiliar with the differences between an insulin syringe and other parenteral syringes. Insulin vials often look alike, leading to mix-ups. Insulin doses drawn into syringes also run the risk of being unlabeled.
Reccomendation:Before transitioning away from insulin pens, conduct a failure mode and effects analysis (FMEA) to proactively address problems that are sure to arise. Reeducate staff regarding injection techniques and measuring doses with insulin syringes. Wherever possible, pharmacy should prepare, label, and dispense daily patient-specific basal insulin. For rapid-acting insulin, vials (3 mL preferred) should be dispensed and labeled for specific patients. Provide insulin syringes in appropriate sizes (1 mL, ½ mL, 0.3 mL) to areas where insulin may be administered and in hyperkalemia treatment kits.

Review of sterile compounding practices (1,2)
Problem: In an ISMP survey, up to 29% of pharmacy technicians reported that contamination of compounded sterile products has happened in their facility during the past year. Only half (50%) of staff pharmacists were confident that contamination had not occurred. A governor-commissioned report in MA on sterile compounding recommends stronger oversight and licensure of compounding pharmacies and calls for pharmacy boards to review compounding activities in hospitals and other locations such as physician offices.
Recommendation: Hospitals should use the Proceedings from the ISMP Sterile Preparation Compounding Safety Summit: Guidelines for Safe Preparation of Sterile Compounds ( as a resource to identify opportunities for improvements in sterile compounding practices in hospitals.

vDrawn curtains, muted alarms, and diverted attention lead to death in the postanesthesia care unit (PACU) (6)
A teen died following a tonsillectomy after receiving a dose of IV fentaNYL in the PACU. Staff identified several causes: 1) After receiving fen-taNYL, the patient was not observed or assessed for 25 minutes due to an emergency with another patient; 2) The alarms on the monitoring equipment had been muted due to alarm fatigue; and 3) A curtain had been drawn around the patient, obstructing the view necessary to maintain an ongoing visual assessment of the patient.
Recommendation: Maintain a direct line of sight to patients. Provide staffing to ensure proper monitoring, especially when IV opioids are administered. Manage alarm hazards by preparing an annual inventory of device alarms, identifying the most important alarms, establishing policies for managing alarms, and educating staff about alarm policies and procedures. Additional strategies can be found in the full article at:

vLook-alike vials of HYDROmorphone and morphine (Westward) (1)
Westward’s 1 mL vials of HYDROmorphone 2 mg/mL and morphine 5 mg/mL may increase the risk of mix-ups between these two drugs due to similar looking vials, especially once the caps are removed.
Recommendation: Do not dispense these vials together to the same patient care area. If possible, dispense only unit dose syringes of these medications. If vials must be dispensed, purchase one of the products from a different manufacturer to help differentiate the vials.

vTretinoin confused with ISOtretinoin (4)
A young patient with acute promyelocytic leukemia (APL) was supposed to receive oral tretinoin (all-trans retinoic acid [ATRA]), but an oncology nurse enrolled the patient and prescriber in the iPledge program and called a prescription for ISOtretinoin in to a local pharmacy. The error was found 4 months later when the patient was admitted to the hospital.
Recommendation:  This type of error associated with similar drug names is best prevented with the use of a well-designed order set for APL, highlighting that tretinoin (and not ISOtretinoin) should be prescribed. Referring to the drug as all-trans retinoic acid rather than tretinoin may help differentiate it from ISOtretinoin; however, use of the acronym ATRA alone is discouraged.

Oral niMODipine liquid administered IV (4)
A patient died after receiving oral liquid niMODipine via a central IV line instead of a nasogastric (NG) tube. The pharmacy, unaware the drug was being given via an NG tube, dispensed capsules, the contents of which were withdrawn into a syringe with a needle and diluted. The drug was accidentally administered IV, resulting in severe hypotension and cardiac arrest.
Recommendation:Pharmacy should prepare all doses of enteral or oral liquid niMODipine. A study provides evidence that the liquid extracted from capsules, stored in amber oral syringes, and placed in light-protected bags, is stable at room temperature for 31 days. A mechanism should be established to alert pharmacy to NG, orogastric, or percutaneous gastric tubes.

Potassium and sodium acetate injection mix-ups (3)
Due to the national shortage of sodium bicarbonate injection, hospitals have been dispensing sodium acetate injection as an alternate alkalinizing agent. Accidentally substituting potassium acetate in dosages commonly used for sodium acetate (e.g., 40 mEq or more) could prove fatal. Focusing on the acetate component of potassium acetate and failing to recognize the potassium component has been one underlying cause of such errors.
Recommendation: Proactive risk-reduction strategies must be identified and implemented when using alternative products during a drug shortage. If used, potassium acetate should be stored in an isolated, designated area, and pharmacy staff should be educated about the unique location of the product and the related safety issue. If available, use pharmacy workflow software with barcode scanning capability to prevent mix-ups between sodium acetate and potassium acetate. 

vMetoprolol mistaken as methadone on computer screen (6)
A nurse gathering a drug history on a new patient inadvertently selected methadone 100 mg BID from the computer screen instead of metoprolol 100 mg BID. The physician reviewed the medication list and continued all the medications. The pharmacist questioned the high methadone dose, but the physician instructed to give the medication as written. After receiving 2 doses, the patient experienced a cardiorespiratory arrest.
Recommendation: Use tall man letters to distinguish these two drugs in computer listings. Require prescribers to specify the indication if methadone is prescribed. If the patient is being treated for opioid addiction, confirm the dose with a methadone clinic. Have the patient/caregiver confirm (even sign) the medication reconciliation list to verify accuracy. All questionable orders must be fully resolved before dispensing and administering the medication.

Acetaminophen suspension (PrecisionDose) labeling could lead to pediatric overdoses (1)
The word “Children’s” is on the container labels of 325 mg and 650 mg unit dose cups of acetaminophen oral suspension (PrecisionDose). This implies that the total dose in the cup is suitable for children. Depending on the child’s age and weight, 325 mg or 650 mg might represent an overdose.
Recommendation:  PrecisionDose was made aware of the problem and is looking into the matter. For children, pharmacy should dispense patient-specific doses of acetaminophen suspension in oral syringes. The unit dose cups should only be dispensed if the child’s dose is the total dose in the cups.

Reduce zolpidem (AMBIEN and generics) dose in order sets (4)
Because certain people experience impairment of alertness in the morning after taking zolpidem, FDA has asked manufacturers to lower the recommended dose for women from 10 mg to 5 mg for immediate-release and from 12.5 mg to 6.25 mg for the extended-release products. Consideration of these lower doses is recommended for men as well. 
Recommendation: If zolpidem (Ambien and generics) is included on order sets, ensure that the doses are adjusted accordingly. Have pharmacy screen orders for zolpidem to monitor adherence to the new FDA dosing recommendation.

Solu-MEDROL (methylprednisolone) dose confusion (3)
With a shortage of methylPREDNISolone sodium succinate in 40 mg and 125 mg vials, SOLU-MEDROL 500 mg vials have been used. Two formulations are available and packaged in similar looking cartons. The Act-O-Vial of Solu-MEDROL provides 500 mg/4 mL once the diluent in the chamber is mixed with the lyophilized powder. The other Solu-MEDROL product, which provides only the powder, results in 500 mg/8 mL after dilution according to the labeling. The differing strengths could lead to dosing errors.
Recommendation: ISMP spoke with Pfizer about our concerns and encouraged the company to make these packages look different. When possible, stock only one of the two available formulations of Solu-MEDROL. If a change in the formulation or strength is required due to ongoing shortages, affix auxiliary labels to vials to alert staff to the new concentration after dilution.

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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