Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook


ISMP Quarterly Action Agenda -April-June 2010

From the July 15, 2010 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 April-June 2010 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 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 Web site. Continuing education credit is available for nurses at:       

Key: v  — ISMP high-alert medication

vCommon risks associated with heparin (7)
Problem: Since 1996, ISMP has published more than 100 reports about heparin errors. The latest event involved a child who died after receiving a large overdose of IV heparin due to an infusion pump setting error that was not detected during a verbal checking process. The pump was a smart pump with a drug library and dose-checking capabilities, but this feature was not utilized.           
Recommendation:  Identify and remove barriers to utilizing smart pump technology. Examine internal errors associated with heparin and common risks (e.g., programming errors, mix-ups with other drugs, compounding errors, concomitant administration of heparin-type products) listed in Table 1 ( to identify weaknesses. Implement key improvement strategies found in Table 1 and in the ISMP Medication Safety Self Assessment for Antithrombotic Therapy (

v Confusion between organ preservation solutions (i.e., VIASPAN and SPS-1) and IV containers (7)
Problem: Cold storage solutions used to preserve harvested organs are available in plastic bags that resemble IV bags and also contain a port that will accommodate IV tubing. An organ procurement team left a liter bag of ViaSpan in a hospital where it was later returned to the hospital’s pharmacy with other IV solutions. Inadvertent IV administration of organ preservation solution would cause cardiac arrest due to the high amount of potassium.
Recommendation:  Alert operating room staff of the possibility for mix-ups between organ preservation solutions and IV containers. If organ preservation solutions are routinely stored at your hospital, sequester the solutions away from other IV solutions and apply auxiliary warning labels to the outerwrap noting that this concentrated electrolyte solution is to be used only for the storage or flushing of harvested organs.

v Another fatal event with IV bupivacaine  (10)
Problem: ISMP previously described an event involving a young pregnant woman who died after she accidently received an IV infusion of epidural bupivacaine and fentaNYL. More recently, news media from the United Kingdom reported that a hospital trust would be sentenced by a court after one of its own nurses died when she was given IV bupivacaine instead of saline shortly after giving birth.
Recommendation: Obstetrical units need to evaluate and address bupivacaine toxicity that results from accidental IV injection. Inherent risks associated with routinely prescribing, dispensing, storing, and administering both epidural and IV solutions, and other medications during labor and delivery should also be identified and addressed.

Common pitfalls when conducting a root cause analysis (RCA) (8)
Problem: ISMP continues to observe common pitfalls encountered while conducting a RCA, often rendering the process less useful than intended. Common problems include: failing to establish a sequence of events; over-reliance on written policies and procedures to illustrate what normally happens when providing care; failure to conduct investigations for all at-risk behaviors and human errors identified; not seeking external information about similar adverse events; selecting weak error-reduction strategies; and others.
Reccomendation: Ensure that the RCA includes an accurate sequence of events. Investigate “what normally happens” rather than just relying on “what policies and procedures require.” Identify conditions that led to at-risk behaviors, and discover the deep system-based causes of events (see probing questions in Table 2 at: Search professional literature for similar events, and choose error-reduction strategies which are more resistant to human error. Carry out action plans and measure your success.

v Propofol container labels highlight the percent concentration, not the mg/mL strength (8)
Problem: Propofol 5 mg (0.5 mL) was ordered for an agitated pediatric patient following extubation. The nurse accidently gave 5 mL (50 mg) of propofol. The propofol (DIPRIVAN) vial had a pharmacy label covering the mg/mL strength, so the only visible portion of the label stated “propofol 1%.” Also, due to the propofol shortage, the imported product sold by APP pharmaceuticals and manufactured by Fresenius Kabi, only highlights the strength as 1%, making it difficult to determine the mg amount.
Recommendation:  To reduce the risk of calculation errors, hospitals using the imported product should add an auxiliary label to draw attention to the mg/mL strength. Pharmacy-applied labels, however, should never obscure critical information on the manufacturer’s label.

vPrevent vinCRIStine wrong route injections (10)
 More than 50 fatalities have been reported after administering vinCRIStine via the intrathecal route; the few patients who survived this type of error have permanent neurological deficits. The most recent fatal event occurred in an adult patient who had been receiving IV vinCRIStine as well as intracerebroventricular methotrexate through an Ommaya reservoir. The patient inadvertently received vinCRIStine via the Ommaya reservoir.
Recommendation: Safety practices to prevent this error can be found at: and ISMP and the World Health Organiza-tion suggest dispensing and administering vinCRIStine diluted in a minibag, and to separate IV and spinal medication delivery times. Medica-tion safety teams/committees may want to view the free FDA Patient Safety Video on this topic at:

vSafe practice with the once daily opioid Exalgo (HYDROmorphone extended-release) (10)
Recently FDA approved Exalgo, which is indicated for the management of moderate to severe pain in opioid-tolerant patients requiring continuous opioid analgesia for an extended period of time. Confusion between immediate- and extended-release products could result in an overdose, which may lead to serious adverse events such as respiratory depression and death, or an underdose, leading to poor efficacy.
Recommendation:When prescribing Exalgo, include the proprietary name, and if the established name is used, spell out “hydromorphone extended-release.” If prescribing immediate-release HYDROmorphone, do not attach modifiers such as “IR.” Before dispensing or administering Exalgo, verify that the patient is opioid-tolerant, counsel patients on how to properly take Exalgo, and encourage patients to read the Medication Guide.

 vFailure to set a volume limit for a magnesium bolus dose leads to harm (11)
 An obstetrician prescribed an IV magnesium sulfate bolus dose of 6 g/30 minutes followed by a continuous infusion of 2 g/hour for a patient in preterm labor. A nurse obtained a 20 g/500 mL bag of magnesium sulfate and programmed the bolus to be delivered as a continuous infusion at 12 g/hour with no volume limit. The nurse forgot to return to the patient’s room in 30 minutes to reprogram the rate to 2 g/hour. The smart pump did not provide a hard stop to prevent the administration of an excessive dose of magnesium sulfate.
Recommendation:  Never infuse an IV magnesium sulfate bolus dose from the maintenance solution unless: 1) The bolus dose is delivered using the bolus dose feature; 2) Separate dose limits are operational for bolus and maintenance doses; 3) These alerts are configured as a “hard stop,” and 4) A qualified nurse remains at the bedside during infusion of the bolus dose to monitor the patient for signs of magnesium toxicity. If all these conditions are not met, administer the bolus dose from a separate container.

Questionable safety with continuous inhalation albuterol infusion set-up (11)
Albuterol inhalation solution was added to an IV bag with tubing that was fit into a nebulizer to provide continuous respiratory therapy to status asthmaticus patients. A nurse discovered that a patient’s IV medications had been infused into the IV tubing connected to the nebulizer. This practice could also lead to accidental IV delivery of inhalation drugs.  
Recommendation:  Avoid this risky practice by only adding the inhalation solution directly into a nebulizer cup as needed.

The Centers for Medicare & Medicaid Services (CMS) 30-minute rule may result in unintended consequences (12)
 The CMS regulation that requires medications to be administered within 30 minutes before or after their scheduled times, may be causing nurses to drift into unsafe work habits in order to meet the rule, such as pre-pouring medications, pre-charting medication administration, and removing medications for multiple patients at the same time.
Recommendation:  Consider the risks inherent in the workarounds that may be taken to comply with the 30-minute rule, and remind nurses that exact timeliness with scheduled medications is frequently less important from a clinical perspective than making sure the correct patient receives the correct medication.

vEPINEPHrine pre-filled syringe shortage: Safety concerns with available alternatives (12)
EPINEPHrine emergency syringes 1 mg/10 mL (0.1 mg/mL) are currently on backorder from the sole manufacturer of this product. Although injectable EPINEPHrine is still available in other forms, these products may not be safe alternatives.
Recommendation:  Pharmacists should communicate information about the shortage and recommended substitute products to all potential areas where EPINEPH-rine emergency syringes are used. Conserve current supplies of syringes for code boxes and emergency responders where pharmacists would not be present during a code. Review the safety concerns associated with the available injectable products and corresponding error-reduction strategies at:

Preventing errors when administering drugs via an enteral feeding tube (7,9,10,11)
 Medication errors related to the administration of drugs via an enteral feeding tube can result due to the incompatibility of administering medications via a tube, improper preparation of medications, and/or using improper administration technique. Such errors can lead to an occluded feeding tube, reduced drug effect, or drug toxicity.
Recommendation:  A team of nurses, pharmacists, nutritionists, and physicians should develop protocols for administering drugs through enteral feeding tubes that address using appropriate dosage forms, preparing drugs for enteral administration, administering each drug separately, diluting drugs as appropriate, and flushing the feeding tube. Protocol guidance is available at:

 Infusion pump safety issues with Baxter Colleague Volumetric Infusion Pumps and Hospira Symbiq (9)
FDA has ordered Baxter to recall and destroy all Colleague pumps because the company could not address known safety issues within an acceptable timeframe. The Hospira Symbiq infusion pumps may not detect air in the line if a clinician programs the pump to infuse more volume than in the bag/bottle. Also, unrestricted flow can occur with Symbiq, if the cassette is removed before the cassette carriage is in the fully-open position.
Recommendation:  Continue to use Baxter Colleague pumps while Baxter works with the FDA to develop a transition plan. For strategies to mitigate risks with these pumps, visit: If using Hospira Symbiq pumps, review the safety steps outlined by the company with your frontline staff ( and

The American Association for Respiratory Care (AARC) statement on inhaled medication dosing times  (12)
AARC has a position statement on inhaled medication dosing times that differs from the CMS regulation re-quiring administration within 30 minutes of the scheduled time. CMS supports the AARC suggestion of an administration window that does not exceed 60 minutes before or after the scheduled administration time.
Recommendation: Keep on file a copy of the AARC position statement ( and CMS support language in case state surveyors or The Joint Commission question the timeframes for inhaled medications.


Debora Simmons is an approved California CE provider of continuing education and complies with the criteria for quality continuing nursing education programming.

Access the CE for Nurses


Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved