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ISMP Medication Safety Alert


ISMP Quarterly Action Agenda - July - September 2006

From the October 5, 2006 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 agenda items have been prepared for your administrative staff 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 July and September 2006. 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 boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Continuing education credit is available for pharmacists and nurses.

EXUBERA (insulin human [rDNA origin]): risk of dosing errors (13)
Problem: Exubera is a new inhaled form of insulin dosed in mg. Confusion between doses ordered in mg and units seems inevitable as the drug will be used in conjunction with injectable insulin. The equivalency of mg to units is not evenly incremental (1 mg is equal to 3 units of insulin, but 3 mg is equal to 8 units, not 9 units). Also, consecutive inhalation of three 1 mg blisters results in greater insulin exposure than inhalation of one 3 mg blister.
Recommendation: To ensure proper use, warn practitioners about the potential for errors when dosing Exubera. Build computer alerts to remind staff that three 1 mg doses should not be substituted for one 3 mg dose due to differences in retention of the drug in the blister packs. Also educate patients about potential dosing confusion before prescribing, dispensing, and/or administering the product.

Serious tissue injury with IV PHENERGAN (promethazine) (16)
Problem:IV administration of promethazine has led to repeated cases of severe tissue damage that often required surgical intervention, including fasciotomy, skin graft, and even amputation. In one of the most recent events, IV administration of promethazine led to the amputation of a thumb and fingers of a 19-year-old woman who was suffering from flu-like symptoms.
Recommendation:Limit the concentration to 25 mg/mL strength; dilute the drug further in 10-20 mL of normal saline; administer the drug slowly through large-bore veins. Build alerts to appear on computerized prescriber order entry systems,  MARs, and automated dispensing cabinet screens. Use alternatives such as 5-HT3 antagonists when appropriate. Additional recommendations can be found in the newsletter article.

Double keying errors with a Hospira Plum A+ infusion pump (15)
Problem:When programming a Plum A+ pump, there is a slight delay before the number appears on the screen. A nurse pressed “4” and when it did not immediately appear on the screen she pressed the key again, leading to infusion of TPN at  445 mL/hr instead of 45 mL/hr. Accumulation of dirt or sticky substances (e.g., glucose) under the keys has caused similar problems with other pumps.
Recommendation: Require nurses to review pump settings before leaving a patient’s room. Include the potential for double keying errors (including the types mentioned in our January 12, 2006 news-letter) in new pump evaluations. Although dose limits for TPN may not be appropriate, an infusion rate limit should be set for TPN and general infusions (e.g., 200 mL/hr) when pumps with dose checking capabilities are available.

Designing effective warning labels (17)
Problem:Warnings offer a valuable strategy for providing important safety information. However, the design of the warnings often fail to influence staff behavior in ways intended to improve safety.
Recommendation: To be effective, warnings must reach their target audience, capture their attention, and cause the recipient to understand, agree with the warning, and respond accordingly. They should be designed in a way that: takes into account the lowest level of ability among the target audience; uses larger fonts with adequate white spacing between words; are presented in mixed letter case (not all capital letters); and uses signal words like danger and corresponding color backgrounds (e.g., red background, white lettering for danger). Additional recommendations appear in the newsletter article.

Medication reconciliation: practitioners report frustration and difficulties (14)
Problem: Results of our survey of more than 1,400 healthcare providers indicated that many were just beginning to develop a workable medication reconciliation process. While the vast majority felt the process was valuable to patient safety, more than 300 insightful comments clearly showed frustration and difficulties with implementing these processes. For example, a quarter of respondents did not know who was responsible for sending the patient’s medication list to the next provider upon discharge, and many were unsure of the time in which medications must be reconciled at their facility.
Recommendation: Visit to read respondents’ comments regarding the difficulties with implementing medication reconciliation. Teamwork among disciplines and clearly defined protocols were ranked as the most important factors for success; unreliable patient histories and lack of physician leadership were cited as the most significant barriers. See our April 21, 2005, newsletter for recommendations regarding an effective medication reconciliation process.

Calling community pharmacies during medication reconciliation (19)
Pharmacists who work in community and mail-order pharmacies may be unaware of the reconciliation process used in hospitals and, thus, may be uneasy or resistant to sharing information about a patient’s current medications.
Recommendation: As feasible, contact pharmacies in the nearby community to allay any apprehension about releasing important medication information. To make community pharmacists more comfortable, suggest that they call back the hospital staff member through the central phone system to validate the source of the request.

MUCINEX (guaifenesin) and MUCOMYST (acetylcysteine) mix-ups (16, 18)
Mix-ups between these drugs have happened. In the most recent case, a nurse incorrectly transcribed a telephone order as Mucomyst, but the error was recognized after the pharmacist found it unusual that a stop date had not been prescribed and then discovered that the patient did not have an acetaminophen overdose. However, Mucomyst is sometimes prescribed without a stop date for interstitial lung disease, so mix-ups may be more difficult to uncover.
Recommendation: Require verification of the indication for either drug when prescribed, and install a computerized reminder that generates an alert when entering prescriptions for these drugs. Spelling the drug name when reading back telephone orders can help avoid miscommunications.

AZILECT (rasagiline) and ARICEPT (donepezil) name mix-ups (19)
These medications can look alike when handwritten and can also sound alike during telephone orders.
Recommendation: If these drugs are available in your facility, set a look-alike alert in the computer system and match the drug’s indication to the patient’s diagnosis before dispensing either drug.

NEULASTA (pegfilgrastim) and LUNESTA (eszopiclone) potential name mix-up (19)
These medications can look alike when handwritten and can also sound alike during telephone orders.
Recommendation: Prescriptions for either drug should include both the brand and generic names. Practitioners should also match the drug’s indication to the patient’s diagnosis to confirm the correct medication. Patients should be alerted to the possibility of confusion between these products when picking up outpatient prescriptions.

ADACEL (Tdap) and DAPTACEL (DTap) confusion (17)
The similarities of brand names, generic designations, vaccine abbreviations, and packaging have led to several mix-ups between these two products. Most often, adults have received the pediatric vaccine, which contains greater amounts of the detoxified pertussis toxin and diphtheria toxoid. Many drug information systems and wholesalers list the component antigens of Adacel as diphtheria, tetanus, and acelluar pertussis, rather than the way they are  listed on the package label, with tetanus first, making it easier to confuse these products.
Recommendation: Separate the stock of the pediatric and adult formulations, and place alerts on the products and in computer software to remind practitioners about the differences between these two products. If possible, configure the order entry system to disallow selection of the wrong product based on the patient's age. Also, verify the patient's age before dispensing or administering any vaccine. Check how these products are listed in your drug information systems and make alterations as needed to avoid confusion.

Fatal heparin overdoses caused by restocking error in an automated dispensing cabinet (ADC) (19)
Three premature infants died after receiving an overdose of heparin via flush solutions prepared for umbilical lines. One mL vials that contained 10,000 units/mL were placed incorrectly into a unit-based automated dispensing cabinet (ADC) where 1 mL vials of heparin, 10 units/mL, were normally kept. Look-alike labels and packaging played a role in the error.
Recommendation: Require a double check of products pulled for restocking ADCs before they leave the pharmacy. If possible, avoid stocking the 10,000 units/mL strength of heparin in the pharmacy, and have pharmacy dispense flush solutions as needed. Assess the medications and strengths currently stocked in ADCs in neonatal and pediatric units (crash carts, too). Remove any products considered unsafe and have pharmacy provide the medication as prescribed. Take steps to reduce the risk of confusing products with look-alike labels and/or packages. Consider the use of bar-code technology when stocking and removing medications from ADCs.

Baxter adenosine syringe incompatible with CLAVE needleless system (19)
Baxter’s prefilled syringes of adenosine (6 mg/mL, 2 mL syringes) are incompatible with the CLAVE intravenous system needleless connectors, such as those on Hospira solution administration sets with the LifeShield CLAVE connector. During an emergency, precious time could be lost if the drug cannot be connected to the patient’s IV line.
Recommendation: Until this incompatibility is resolved by the manufacturer, consider replacing these syringes with ADENOCARD brand syringes on crash carts and in unit stock or automated dispensing cabinets.

DIASTAT ACUDIAL (diazepam rectal gel) dosing errors (18)
Errors have occurred with this medication when the product syringe was not dialed, set, and locked to the prescribed dose by the dispensing pharmacist, even if the maximum dose available in the syringe (10 mg or 20 mg) had been prescribed. Some of the dosing errors have led to respiratory depression requiring emergent interventions.
Recommendation: Pharmacists should check that the dose has been dialed and locked for both syringes in each package. Practitioners should educate patients and caregivers on how to use the device, including confirming that the prescribed dose is visible in the display window, the green “ready” band is visible, and the smaller rectal tip size is used if the patient is a child.

The ISMP Quarterly Action Agenda is now approved for Continuing Pharmaceutical Education by the Pennsylvania Society of Health-System Pharmacists. Each Action Agenda will be approved for one contact hour of continuing education (0.1 CEU).
Learning objectives and instructions for applying for CE are available at the PSHP CE Center.

The Pennsylvania Society of Health-System Pharmacists is approved by the American Council of Pharmaceutical Education as a provider of continuing education and complies with the criteria for quality continuing pharmaceutical education programming.

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


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