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


ISMP Quarterly Action Agenda - july - september 2012

From the October 4, 2012 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 July-September 2012 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 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 at: Continuing education credit is available for nurses at:

Key: v  — ISMP high-alert medication

vPotassium chloride (KCl) injection concentrate in a syringe (15)
Problem: Due to a shortage of KCl injection concentrate in vials and pharmacy bulk packages, a technician purchased KCl 20 mEq syringes from an outsourcing company. The syringes were left on a counter after removing an overwrap with a warning statement. A pharmacist thought these were cefazolin syringes because they had a similar red cap and placed them in the refrigerator with other cefazolin syringes. Fortunately, she noticed her mistake.
Recommendation:The company no longer provides KCl syringes but other companies may do so. KCl vials must have a black cap and closure that states, “Must be Diluted.” Unlike syringes from which a drug can be directly injected, vials signal that additional steps are needed prior to injection. ISMP urges hospitals to only purchase KCl in vials, not syringes, and to never remove caps or overwraps with warning statements until just prior to use.

vInappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections(19)
Problem: Some staff have been using pharmacy bulk packages (PBPs) of contrast media inappropriately as multiple-dose containers for multiple patients in radiology, cardiac catheterization lab, and cardiac surgery locations. Staff may believe the PBP is a multiple-dose container because some manufacturers refer to it as a “multipack” and some power injector manufacturers suggest such use. PBPs of contrast do not contain preservatives to help prevent contamination and the spread of infection.
Recommendation: The pharmacy should oversee the purchase, dis-tribution, storage, and use of IV contrast media in all inpatient and outpatient clinical areas. Staff should draw up doses of IV contrast media from single-dose vials or use prefilled single-use syringes from the pharmacy or manufacturers. The contents of PBPs should only be transferred to single-dose containers or syringes in the pharmacy under a laminar flow hood or other USP <797> suitable environment within 4-10 hours of initial entry into the bag.

vMix-ups between methadone and methylphenidate (14)
Problem: A community pharmacy dispensed methadone to a child in a vial labeled with the prescribed drug, methylphenidate. The child required hospitalization but recovered. The mix-up has also happened in hospitals. Both drugs have overlapping tablet strengths (10 mg) and may appear together on computer selection screens.
Recommendation: Configure mnemonics in order entry systems to prevent confusion between methadone and other drugs that start with “met” or “meth” and have similar strengths. Separate methylphenidate and methadone in storage areas. Implement barcode scanning in the pharmacy to identify when the wrong product has been selected from the shelf.

 v Teach patients to remove older transdermal fentaNYL patches (18)
Problem: An unresponsive patient was brought to the hos-pital with multiple fentaNYL patches on his body. The patient followed the directions to “apply one patch every 72 hours,” but was not told to remove the older patch prior to applying a new patch.
Reccomendation: Ensure that patients who are prescribed transdermal patches understand proper use and disposal. ISMP has developed a safety checklist ( that can be used by those providing education and given to the patient afterwards for reference.

vConfusion between EPIPEN (EPINEPHrine injection) training device and active pen (15)
Problem: EpiPens are only available in a 2-Pak containing two EpiPens and a nonfunctioning training pen. The training pen looks similar to the actual Epi-Pen. An emergency department’s automated dis-pensing cabinet was accidentally stocked with an EpiPen training device instead of the active pen. 
Recommendation: If hospitals store EpiPens on clinical units or in code carts, remove the pens from their carton and only store the active pens in unit stock. Be sure staff know about the risk of confusion between the training pens and actual pens.

Generic methylergonovine maleate and ENGERIX-B (hepatitis B vaccine) mix-ups (17)
 Novartis sent a letter to hospitals that highlighted the accidental administration of methylergonovine to newborns instead of the ordered hepatitis B vaccine. Two of the recent mix-ups involved generic methylergonovine and Engerix-B, which are packaged in vials that look very similar.
Recommendation: Separate newborn medications from those used for mothers. If newborn and perinatal medications must be stored together in automated dis-pensing cabinets, use locked, lidded medication bins for pediatric products and highlight whether medications are for the mother or infant on the selection screen. If possible, administer infant medications in an area separate from where medications are administered to the mother.

vProtocol needed for drug concentration change (15)
A DOCEtaxel order was entered into the pharmacy computer system. The pharmacy technician preparing the product discovered that the DOCEtaxel concentration in stock had changed. The computer system did not have the new concentration listed in its inventory, so the drug amount on the label in mL was incorrect.
Recommendation: When purchasing alternative products or strengths that are different than normally stocked, a verification process is needed to ensure that changes are made in computer systems, includ-ing IV compounders and robots, automated dis-pensing cabinets, computer order entry systems, smart pumps, and other affected technology.

vUnnecessary drug release time (72h) within fentaNYL order misunderstood as dose (14)
An order for “fentaNYL transdermal 72h apply 1 patch 12 mcg/hour externally q3d” was misunderstood as 75 mcg/hour. The number 72 was mis-read as 75 and mistaken as the mcg/hour dose.
Recommendation:  Advise prescribers to avoid listing the patch release rate (72h) when ordering fentaNYL patches. Ensure that patients who receive fentaNYL patches are not opioid naïve. 

vMedication within IV tubing may be overlooked  (16)
A nurse flushed a post-op patient’s IV line previously used by anesthesia. The patient became unresponsive because several mg of rocuronium present in the tubing was inadvertently flushed into the patient. Depending on the drug concentration, IV set volume, and point of injection, unintended doses of drugs are possible when flushing lines or administering IV medications.
Recommendation: Flush IV lines as proximal to the patient access site as possible after clamping the line immediately above the point of injection. For IV piggybacks, the insertion point should be at a Y-site closest to the patient’s access site. Post-procedure, anesthesia should flush lines or change the tubing, and remove any source medication container, prior to extubation.

Avoiding inadvertent IV injection of oral liquids (17)
Not all graduate nurses know that oral syringes are available, their purpose, or how to use them. One nurse expelled an oral syringe of LORazepam into a parenteral syringe and administered it IV after voicing frustration that the pharmacy-dispensed syringe could not be connected to the IV port. Another nurse expelled oral morphine solution into a dosing cup, diluted it, drew it into a parenteral syringe, and injected it IV.
Recommendation: Include education on accidental injection of oral liquids and the purpose for using oral syringes during nursing orientation and new graduate mentorship. Ensure that oral syringes are available in all patient care units, and affix auxiliary labels that state “ORAL” to all medications dispensed in oral syringes.

Remove glacial acetic acid from pharmacies (19)
Several patients sustained severe skin or mucosal burns after undiluted glacial acetic acid (99.5%) was dispensed and applied instead of a 5% acetic acid solution. The strength of the solution was not readily visible on the bottle label, and the pharmacist believed glacial acetic acid was a 5% solution pre-diluted by the manufacturer.
Recommendation:  Remove glacial acetic acid from the pharmacy and replace it with vinegar (5% solution) or commercially available diluted acetic acid. Educate staff about the differences between glacial acetic acid and lesser concentrations. Take precautions if pharmacy dilution of acetic acid must occur, including development of a standard mixing procedure and double-checks. 

Just Culture and its critical link to patient safety (Part 1 and 2) (10,14)
Organizations sometimes provide hasty affirmations that they are operating within a Just Culture, when direct observations belie such affirmations. As a result, Just Culture has simply become a popular catch phrase for many, without full understanding of its tenets and nuances, and its critical link to patient safety.
Recommendation:  To assess how far along an organization is on its  journey to a Just Culture, consider the self-assessment questions in ISMP’s Just Culture newsletter series ( and, and consider participating in the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (

Red flags that represent credible threats to patient safety (15)
Intimidation in the workplace has repeatedly surfaced as a significant barrier to safety. A less obvious but dangerous environment exists when staff speak up about concerns but are too easily convinced that they are unfounded, and when the person being questioned has not perceived the concern as a credible threat. A natural deference to expertise can lead to unintended complacency and tolerance of risk that goes unchallenged.
Recommendation:  Raise the index of suspicion for errors, always anticipating and investigating the possibility when anyone, regardless of experience or position, voices a concern or when patients are not responding to treatment as anticipated. Staff need to trust in their own experiences to augment the expertise of others, and to be receptive to staff who ask questions. Visit for a list of skills to encourage appropriate responses to concerns.

vISMP survey reveals user issues with CARPUJECT prefilled syringes (16)
An ISMP survey of 540 nurses using Carpuject prefilled syringes found that 68% were unaware of significant cartridge overfill that could lead to overdoses. Nurses also reported using the prefilled cartridges as multiple-dose vials, risking contamination and unlabeled syringe contents. Factors that encourage this practice include unavailability of Carpuject syringe holders, the need to dilute the product, and preventing drug waste.
Recommendation: Do not use the Carpuject cartridges as multiple-dose vials. Drugs that require further dilution should be prepared by pharmacy when possible. If dilution is required on the unit and a 1:1 ratio is acceptable, drawing a small volume of a diluent from a single-dose vial directly into a cartridge (1 mL fill or less) may be considered. Provide an adequate supply of Carpuject syringe holders.

vMylan’s melphalan diluent vial confused as actual drug vial (17)
Mylan’s lyophilized melphalan is co-packaged with a diluent that is not clearly labeled and has been confused as the actual drug. The vials of drug and diluent are the same size, both have white caps and similar label colors, and the diluent label has the drug name listed prominently. 
Recommendation: Add an auxiliary label to the diluent to properly identify it, or, until improved labeling by Mylan, search for a different manufacturer for this product. 

vNOVOLOG FLEXPEN (insulin aspart) dose misread by patient (17)
A patient administered 46 units instead of 6 units of insulin when she misread the dose she had dialed using a NovoLOG FlexPen by reading the numbers to the right of the dosing window, not within the dosing window. Other pen issues experienced by patients include inserting the needle but not pressing the button to release the dose or turning the dial to release the dose. 
Recommendation: Patients who are prescribed an insulin pen should meet with a certified diabetes educator, pharmacist, or nurse to demonstrate proper dose selection and use.

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