October – December 2015
ISMP
QuarterlyActionAgenda
Oneof themost important ways toprevent medication errors is tolearn about problems that haveoccurred in other organizations and tousethat information toprevent similar problems at your practicesite. Topromotesuch
aprocess, thefollowing selected items fromtheOctober—December 2015 issues of the ISMPMedication Safety Alert! havebeen prepared for an interdisciplinary committeetostimulatediscussion and action toreducetherisk of
medication errors. Each itemincludes abrief description of the medication safety problem, afew recommendations toreduce therisk of errors, and theissuenumber tolocateadditional information as desired. Look for our high-alert
medication icon under theissuenumber if theagendaiteminvolves oneor moremedications on the ISMP List of High-Alert Medications (www.ismp.org/sc?id=479). TheAction Agendais alsoavailablefor download in aMicrosoft
Word format (www.ismp.org/newsletters/acutecare/articles/ActionAgenda1601.doc) that allows expansion of thecolumns inthetabledesignated for organizational documentation of an assessment, actions required, and assignments for
each agendaitem. Continuing education credit is availablefor nurses at: www.ismp.org/sc?id=480.
Key:
Problem
No.
(20)
(20)
—ISMP high-alert medication
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Severe harm and death from errors and drug interactions with low-dose methotrexate
One harmful and two fatal errors with lowISMP recommends three strategies in its
dose oral methotrexate have been reported.
Targeted Medication Safety Best Practices:
Two of the patients who suffered severe toxic
use a weekly dosage regimen default when
events were taking no more than 20 mg of
oral methotrexate orders are entered; require
methotrexate per week. Incidents occurred
a hard stop verification of an appropriate
due to a combination of baseline patient risk
oncologic reason for daily orders; and educate
factors (renal dysfunction, hypoalbuminemia), patients prior to discharge, including reminding
drug-drug interactions (amoxicillin,
patients that taking extra doses is dan-gerous,
leflunomide, diclofenac), and medication
and providing them with a free ISMP hand-out
errors (pharmacy labeling error led to daily
(www.ismp.org/sc?id=316). Employ drug-drug
use).
and drug-disease interaction screening and
resolve alerts with prescribers. Screen patients
for risk factors and obtain baseline and periodic
lab studies.
Cytarabine and vinorelbine vials from Hospira
have the same label color and green cap, and are
the same size. A vial turned to expose only the
final syllable of the name “...bine,” which is
common to both, can further increase the risk of
confusion. Since cytarabine is approved for
intrathecal use, a mix-up resulting in intrathecal
administration of vinorelbine is likely to result in
a fatal event.
Look-alike vials of cytarabine 100 mg/5 mL and vinorelbine 50 mg/5 mL
Although practitioners should read the full
label on all vials, it is unsafe to store lookalike vials near one another. Isolate one of
them until a secondary supply can be
obtained from a different manufacturer.
The use of barcode scanning verification
during product preparation may also avert
these types of mix-ups.
Will patients ever be free from iatrogenic harm?
January 28, 2016
ISMP MedicationSafetyAlert!

QAA 1
October – December 2015
ISMP
QuarterlyActionAgenda
Organization
Assessment
No.
Problem
Recommendation
(25)
Fifteen years after the Institute of Medicine
published To Err Is Human, patient safety
concerns remain a serious public health
issue. An expert panel convened by the
National Patient Safety Foundation is calling
for action by government, regulators, health
professionals, and others to place higher
priority on patient safety science and
implementation.
The panel made eight recommendations that
focus on: a safety culture; oversight of
patient safety; outcome-based safety
metrics; funding for research; addressing
safety across the entire continuum; support
of the healthcare workforce; partnership
with patients and families; and technology
optimization. See the full report at:
www.npsf.org/free-from-harm.
(23)
Aggrastat is only available in a premixed bag
with an exit port that should not be used to
withdraw the loading dose. Product labeling
recommends administering the loading dose
directly from the bag, which can be risky
without a smart pump that automatically
switches from the loading dose rate to the
maintenance infusion rate. Manually setting
the pump or using the volume to be infused
to administer the loading dose could lead to
errors if the nurse is distracted or
interrupted.
Safe administration of AGGRASTAT (tirofiban) loading doses
If available, use smart pumps with bolus
dosing features to deliver loading doses.
Alternatively, the manufacturer
recommends hanging the bag with a
primed infusion set, and then withdrawing
the required bolus dose from a port on the
infusion set with a syringe. The bag tubing
should then be clamped, and the loading
dose administered over 5 minutes via a
port close to the patient’s access site. The
tubing should then be opened and the
maintenance infusion started.
(25)
Action Required/
Assignment
Date
Completed
Implement the 2016-2017 Targeted Medication Safety Best Practices for Hospitals
ISMP has launched the 2016-2017 Targeted Best Access the 2016-2017 Targeted Best
Practices to mobilize widespread adoption of a
Practices at: www.ismp.org/sc?id=417.
few key strategies aiming to prevent repeatedly
Hospitals that have not implemented the
report-ed harmful medication errors. The five
six 2014-2015 Targeted Best Practices are
new Targeted Best Practices deal with safe
encouraged to do so as a priority, while
storage of neuromuscular blocking agents, use of implementing the five new 2016-2017
fully enabled smart pumps when administering
Targeted Best Practices.
high-alert medications, making reversal and
rescue agents available, eliminating storage of 1
liter bags of sterile water in patient care areas,
and verifying the ingredients prior to mixing
when compounding sterile preparations.
Key vulnerabilities in the surgical environment: Container mix-ups and syringe swaps
January 28, 2016
ISMP MedicationSafetyAlert!

QAA 2
October – December 2015
ISMP
No.
Problem
(22)
Container mix-ups and syringe swaps are
problematic in perioperative areas. During
knee surgery, a woman received tranexamic
acid intrathecally after the 10 mL vial was
mixed up with the same size vial of
bupivacaine. Nearly a dozen of these mix-ups
are in the literature, some leading to
fatalities including a young mother in labor. A
study found that 1 in 20 perioperative
medication administrations and half of all
surgical procedures resulted in a medication
error—-more than one-third of the errors led
to patient harm.
(22)
(23)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Standardize the anesthesia workspace and
concentrations of high-alert medications.
Remove used and unused medications from
the anes-thesia workspace after completing
each case. Employ barcode scanning of
medications and an automated syringe label
printer. Deliver all drug infusions via a smart
pump with activated dose-checking software.
Require the use of commercially available,
outsourced, or pharmacy-prepared syringes
and infusions. Provide dedicated anes-thesia
automated dispensing cabinets in operating
rooms and procedural areas that
communicate with the pharmacy when drugs
are removed.
Confusing volume on OBIZUR (anti-hemophilic factor [recombinant], porcine sequence) vial
Pharmacy staff have been misled by the “3 mL”
Make pharmacy staff (e.g., pharmacists,
designation on the Obizur label, which refers to
technicians) aware of the potential for errors
the vial’s size (to facilitate swirling of the
when reconstituting this drug and preparing
reconstituted contents), not the drug volume
patient-specific doses. Include a note in the
after reconstitution. Although a 1 mL syringe of
pharmacy computer and on technician
diluent is provided, a pharmacist assumed the
preparation labels that the final volume in
volume in the vial would swell to 3 mL after
these vials is 1 mL after reconstitution. The
reconstitution. The pharmacist provided the
company has agreed to change the label to
technician with instructions to place 60 mL of
reduce confusion.
the drug in a small infusion bag, when only 20
mL was needed for the patient’s dose.
Mix-ups when measuring oral liquid
medications have occurred when using cups or
syringes with household or other non-metric
measures. In order to prevent errors, we
recommend purchasing oral liquid dosing
devices that only display the metric scale.
However, current metric-only dosage cups may
have scales that are embossed on clear plastic,
making them difficult to read.
Oral devices with mL-only dosing marks
More oral devices, including oral syringes
and dosage cups, with metric-only dose
scales are becoming available and should
be used to prevent measurement errors.
Some of these dosing devices have
gradation markings in black, making the
scales easier to read.
Continued confusion between calcium gluconate and sterile water for injection vials
January 28, 2016
ISMP MedicationSafetyAlert!

QAA 3
October – December 2015
ISMP
QuarterlyActionAgenda
Organization
Assessment
No.
Problem
Recommendation
(20)
Close calls and mix-ups with look-alike 10 mL
vials of Fresenius Kabi calcium gluconate 1 g/10
mL and Hospira sterile water for injection
continue. A pharmacy recently sent a vial of
calcium gluconate instead of sterile water for
injection to reconstitute a vial of ampicillin for a
neonate. Fortunately, the nurse realized that an
incorrect diluent had been sent.
Fresenius Kabi has made label changes to its
calcium gluconate product to reduce
similarities. The company anticipated a late
November or December (2015) release of this
product. Consider switching to a 20 mL vial of
sterile water to help differentiate the
products. Barcode scanning, alerting staff to
this risk, and storing these products apart may
help prevent errors as well.
(21)
This brand of oral vancomycin is supplied as a
compounding kit containing two bottles, one
with drug powder and the other with diluent.
Both bottles list “Vancomycin 25” or
“Vancomycin 50” at the top. A nurse removed
one of the bottles labeled “vancomycin” from
the kit and administered only the diluent to a
patient.
(24)
Ratio expressions of single entity drug products
will no longer be allowed as of May 1, 2016. To
prevent confusion, orders for these drugs after
May 1 should include a metric dose. For example,
if a prescriber calls for “1:10,000 EPINEPHrine”
during a code and the product label displays the
strength as 0.1 mg/mL rather than the ratio
expression, practitioners could administer the
wrong strength.
Action Required/
Assignment
Date
Completed
Diluent for FIRST brand of oral vancomycin (CurtisPharma) administered in error
When using this product, prepare doses in
the pharmacy before dispensing. Despite
the expense, provide a few oral
vancomycin capsules in an automated
dispensing cabinet to be used when the
pharmacy is closed.
Farewell to ratio expressions on labels of single entity drugs
Inform prescribers and other healthcare
professionals about the upcoming changes,
and encourage them to use the new dosing
nomenclature when referring to these
medications.
Inadequate treatment doses of HYPERTET (tetanus immune globulin [TIG])
January 28, 2016
ISMP MedicationSafetyAlert!

QAA 4
October – December 2015
ISMP
QuarterlyActionAgenda
Organization
Assessment
No.
Problem
Recommendation
(20)
The Centers for Disease Control and
Prevention (CDC) reviewed tetanus cases in
California over 6 years. Some patients
received a 250 unit postexposure prophylaxis
dose instead of a 3,000-6,000 unit treatment
dose of TIG, due in large part to prescribing
errors. The lack of a specific treatment dose
in the TIG package insert and availability in
250 unit prefilled syringes contributed to the
inadequate dosing.
Educate prescribers, pharmacists, nurses, and
other practitioners about the differences
between the treatment and postexposure
prophylaxis doses. Consider adding alerts to
computerized prescriber order entry systems
and pharmacy computer systems. Place
reminders to verify whether the product is
being used for treatment or prophylaxis, and
include appropriate doses for both, in storage
areas or on automated dispensing cabinet
screens.
(23)
(20)
Action Required/
Assignment
Date
Completed
Used oxymetazoline nasal spray restocked because tamper-resistant seal looked intact
A used oxymetazoline nasal spray was placed
Once a product is opened, staff should remove
back in storage with unused sprays. The used
the entire tamper-resistant seal. Review
product was almost administered to a patient,
organizational processes to ensure
except the physician noticed blood on the bottle appropriate steps are in place to distinguish
tip. During initial use, the cap had been twisted
opened containers from unopened containers.
off but the tamper-resistant seal remained
Consider applying an additional tamperlargely intact.
resistant sticker to products when necessary.
Mix-ups continue with look-alike vials of
Bloxiverz 10 mg/10 mL and pharmacy bulk
packages of Vazculep 50 mg/5 mL despite past
warnings in this newsletter, a national alert, and
a letter from the manufacturer. Recently an
operating room automated dispensing cabinet
(ADC) was accidentally stocked with Vazculep
instead of Bloxiverz, which was used in error to
reverse neuromuscular blockade. The patient
required reintubation, mech-anical ventilation,
and treatment of hypertension.
January 28, 2016
Continued BLOXIVERZ (neostigmine) and VAZCULEP (phenylephrine) mix-ups
Eclat Pharmaceuticals, the manufacturer of
both drugs, is changing the label and sent out
auxiliary labels to be used with current stock of
Vazculep 50 mg/5 mL products. While older
product remains in circulation, use of the
auxiliary labels is necessary. Also, Vazculep 5
mL and 10 mL vials should only be stored in
the pharmacy, not in ADCs in patient care
areas, and kept away from supplies of
Bloxiverz. Barcode scanning of containers
could prevent mix-ups.
ISMP MedicationSafetyAlert!

QAA 5