1997 Cheers and Jeers
In 1997, there were some great strides forward as well as a few steps back in medication error prevention. We felt that recognition was due for both, and so, without further ado, here are ISMP's top CHEERS and JEERS:
CHEERS to the pharmaceutical companies responsive to product labeling, packaging, nomenclature and design problems. Marsam redesigned the label for cefazolin 10 g bulk vials to distinguish it more clearly from the 1 g single-use vial. Amgen updated the epoetin alfa label to include a warning about increased mortality when aggressive dosing is used in CHF or angina patients undergoing hemodialysis. Baxa Corporation redesigned the tips of the Exacta-Med oral syringes to minimize the potential for use with needleless IV systems. Bristol-Myers Squibb repackaged Platinol® (cisplatin) to stem errors from mix-ups with Paraplatin® (carboplatin). A special thumbs up to pharmaceutical companies that now obtain practitioner input on potential safety problems with labeling, packaging and nomenclature prior to product launch.
CHEERS to FDA for requiring products containing 30 mg or more of iron per unit to be packaged as individual doses; the new packaging will decrease the number of doses a child could readily ingest. But JEERS to FDA and manufacturers for allowing the product's identity on each UD package to be replaced by iron-related warnings. This could slow ER personnel who need to identify what product was taken in accidental poisoning situations, and it requires pharmacy to repackage the product for use in institutions.
JEERS to those companies that ignore serious medication safety concerns. Confusion about Cerebyx® (fosphenytoin) continues more than a year after product launch with no indication from Parke-Davis that it plans to improve the flawed prescribing system. Pharmaceutical companies confuse both practitioners and consumers by extending product line names to new products that do not contain the same drugs.
JEERS to healthcare plans that place profit over patient safety. As a cost savings measure, one managed care plan covers Pepcid AC 10 mg but not the other strengths, forcing patients on higher doses to take multiple tablets. Washington State's legislature did the same with other drugs, increasing the risk of medication errors, such as underdosing, overdosing or decreased compliance, which may, ironically, increase costs. CHEERS for innovations that help to prevent errors, such as bar code technology, direct physician computer order entry, and Triple i prescription blanks that use anatomical icons to indicate the drug's purpose. These products can reduce medication errors by linking the drug prescribed with its therapeutic use or with the proper patient.
JEERS to the Denver and Toronto criminal justice systems. Three Colorado nurses were indicted in a baby's death because long-acting penicillin was given IV instead of IM after the nurses misinterpreted information on the route of administration. In Toronto, a nurse was indicted after accidentally injecting potassium chloride concentrate instead of furosemide, resulting in the death of a patient. CHEERS to the medical professionals who refused to provide expert testimony against a nurse in another Colorado case in which a patient died. Largely for that reason, the District Attorney did not pursue criminal charges against the nurse who crushed oral medications and administered them IV because the patient refused to take the medications.
CHEERS to companies that provide clear and accurate resource materials and advertisements. While many companies continue to use dangerous abbreviations in advertisements and labeling, Bristol-Myers Squibb voluntarily changed "u" in its Blenoxane® ad to "units" to prevent any possible errors. Due to concern for accuracy, the new Journal of Oncology Nursing requires authors to submit with their manuscript copies of primary dosing references and cited references.
CHEERS to Bridge Medical, Inc., for sponsoring "Beyond Blame," a video that premiered at a town hall meeting on medication errors hosted by Dr. C. Everett Koop and attended by 2000 pharmacists during the ASHP MidYear Clinical Meeting in Atlanta. The video and town hall meeting focused on the impact of errors on healthcare professionals who commit them, emphasizing that blaming practitioners will not prevent future errors. By the same token, JEERS to institutions that use a punitive approach to medication errors, which only discourages reporting. Also, JEERS to institutions that still supply potassium chloride concentrate injection to patient care units instead of cost-effective, safer alternatives even though we've reported numerous patient deaths caused by this practice.
Our loudest CHEERS are for practitioners who report adverse drug events to their institutions, the USP-ISMP Medication Errors Reporting Program and the FDA MEDWATCH program. By reviewing and learning about external errors, you can work to prevent the same errors from happening in your organization.