July – September 2015
ISMP
QuarterlyActionAgenda
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 2015 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 brief description of the medication safety problem, a few 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 (www.ismp.org/sc?id=479). The Action Agenda is also available for download in a Microsoft Word format (www.ismp.org/newsletters/acutecare/articles/Action Agenda1504.doc) that allows
expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Continuing education credit is available for
nurses at: www.ismp.org/sc?id=480.
Key:
Problem
No.
—ISMP high-alert medication
Recommendation
Organization Assessment
Action Required/
Assignment
Date
Completed
Pediatric medication safety survey shows improvements still needed
(11,
13)
(13)
Survey respondents reported low
implementation with storing adult, pediatric,
and neonatal medications separately;
prescribing liquid medications in metric
doses; verifying line attachment before
administering infusions; requiring
practitioners to undergo specialized training
and competency validation when working
with pediatric patients; and barcode
scanning breast milk to match the infant
with the mother’s milk prior to feeding. Only
41% of pediatric hospitals, 43% of adultpediatric hospitals, and 19% of outpatient
facilities require verifying the components of
sterile preparations prior to adding them to
a solution.
Survey results indicate that
improvements are still needed to
adequately protect pediatric patients
from harmful medication errors.
Healthcare providers caring for pediatric
patients should assess their current
practices and develop a plan to improve
implementation of the recommended
“best practices” in the survey.
NAN Alert: Medication cups with more than one dosing scale can lead to confusion
A nurse confused two dosing scales on a
Ideally, oral syringes that measure only
plastic medication cup and administered 1
in mL should be used for oral liquid
dram (3.7 mL) instead of the intended 1 mL medications instead of cups. If a dosing
dose of morphine sulfate 20 mg/mL oral
cup must be used, it should only
solution, resulting in a fatal overdose.
measure in mL. Until these cups are
widely available, some suppliers can
customize the cups to measure in mL
October 8, 2015
ISMP MedicationSafetyAlert!

QAA 1
July – September 2015
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date
Completed
only.
(13)
(14)
Ongoing BLOXIVERZ (neostigmine) and VAZCULEP (phenylephrine) confusion
Ongoing reports of potentially harmful
Make pharmacy and OR/anesthesia
mix-ups between look-alike vials of
staff aware of the potential for errors
Bloxiverz 10 mg/10 mL and pharmacy bulk with these products. Pharmacy bulk
packages of Vazculep 50 mg/ 5 mL have
packages of Vazculep should never
been received. Most recently, a Vazcu-lep
leave the pharmacy. Soon, Éclat
50 mg vial was sent to the operating room
Pharma-ceuticals will be packaging
(OR)/anesthesia instead of Bloxiverz. If 5
Vazculep in a box with “Pharmacy Bulk
mL of Vazculep (50 mg) had been
Package” highlighted in a yellow
injected, believing it was Bloxiverz, the
background and the strength
massive overdose could have caused
highlighted in gold. For now, the
extreme hypertension, cerebral vascular
company is supplying alert stickers to
accident, or death.
add to current stock to help staff
recognize the potential for mix-ups.
Name and dosing confusion between mefloquine and MALARONE (atovaquone/proguanil)
Mix-ups have been reported between
Include the brand and generic names
mefloquine and Malarone. Both are used for when prescribing Malarone, and include
malaria treatment or prophylaxis and are
the purpose (e.g., malaria prophylaxis or
available in 250 mg tablet strengths.
treatment) when prescribing either drug.
Mefloquine was prescribed daily instead of
Confirm the drug, frequency of
weekly, and mefloquine was mistaken as
administration, and dose regimen with
the generic name for Malarone and
each order. In order entry systems,
dispensed in error. These mistakes could
establish an alert that will appear if
lead to vomiting, syncope, QT prolongation, mefloquine is prescribed daily and if
paranoia, and inadequate prophylaxis.
Malarone is prescribed weekly.
Guidelines for adult IV push medications
(14)
While the prescribing, preparation, and
administration of IV push medications
has become exceedingly commonplace
as part of a therapeutic standard of care,
the lack of oversight and guidance for
administration practices has led to
October 8, 2015
ISMP held a 2-day summit to address the lack
of standardized practices for IV push
medications. Draft guidelines were developed
and shared on our website for comment. The
final Safe Practice Guidelines for Adult IV Push
Medications can be found here:
ISMP MedicationSafetyAlert!

QAA 2
July – September 2015
ISMP
Problem
No.
significant variability, not only among
organizations, but within organizations;
even among individual clinical units.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date
Completed
www.ismp.org/sc?id=563. Review the
guidelines to identify the associated risks and
consider implementing these safe practices
associated with the use of IV push medications.
Loss of potency with certain medications prepared in advance in BD syringes
(15,
17)
(16)
(17)
Certain medications (e.g., fentaNYL) have
been found to lose potency when prepared
in BD syringes and not administered shortly
thereafter. The rubber syringe stopper in
certain lots interacts with these medications
causing a loss in potency. The syringes
were never approved for use as a storage
system for drugs. This calls into question
pharmacy or outsourcer preparation of unit
dose syringes in advance of anticipated
use.
Limit drug exposure in plastic syringes by
using them promptly after preparation.
However, do not sacrifice safety, and
ensure that any process changes do not
increase the risk of errors. Make clinical
staff aware of the situation and to report
unexpected changes in drug
effectiveness. Assign staff to watch for
updated information from FDA, BD,
ISMP, ASHP, or other alerts regarding the
situation.
RELISTOR (methylnaltrexone) prefilled syringes look like enoxaparin and fondaparinux prefilled syringes
A Relistor syringe (12 mg/0.6 mL) was
Products should remain in their cartons
confused with a generic enoxaparin syringe or blister packs until time of
(150 mg/1 mL, Amphastar
administration, although automated
Pharmaceuticals). The same dark navy
dispensing cabinet (ADC) drawers don’t
color is used with both syringes. There are
always provide enough space. Product
other similarities between the syringes that
barcode scanning prior to dispensing
could also contribute to a mix-up.
and administration will help identify
Enoxaparin syringes (30 mg/ 0.3 mL, Teva)
errors.
also look similar to fondaparinux syringes
(2.5 mg/0.5 mL, Dr. Reddy’s Laboratories).
Stocking mix-ups with intracardiac EPINEPHrine and intravenous (IV) EPINEPHrine syringes
Hospitals have inadvertently purchased
ISMP has requested Hospira to
prefilled syringes of EPINEPHrine 1
consider making the word “intracardiac”
mg/10 mL intracardiac injection rather
more prominent on the label. In the
than the IV formulation, leading to
meantime, hospitals should have a
October 8, 2015
ISMP MedicationSafetyAlert!

QAA 3
July – September 2015
ISMP
QuarterlyActionAgenda
Problem
Recommendation
stocking errors in code carts, unit stock,
and automated dispensing cabinets
(ADCs). Suppliers failing to specify
“intracardiac” on order lists contributed to
the errors, as did a shortage of IV forms
of EPINEPHrine.
process in place to ensure replacement
products ordered during shortages are
appropriate.
No.
(18)
Brintellix 10 mg was dispensed instead
of the prescribed Brilinta 90 mg. The two
medications were stored side-by-side
and the wrong container was selected.
The patient fell and was admitted to a
hospital after taking Brintellix for 9 days.
The US Food and Drug Administration
(FDA) has also issued a warning about
errors, noting over 50 reports have been
received.
(18)
An employee heard a ticking sound from
a sharps container in the emergency
department (ED). A “suspicious
package” code was initiated, and the ED
was closed until an Auvi-Q autoinjector
was identified as the cause. The device
had been brought to the hospital by a
patient who had not reattached the outer
case after use, which allowed the battery
to drain until it emitted a ticking sound as
it died out.
Organization Assessment
Action Required/
Assignment
Date
Completed
Continued BRINTELLIX (vortioxetine) and BRILINTA (ticagrelor) mix-ups
Establishing dose limits in order entry
systems may help detect mix-ups if 90 mg
of Brilinta is ordered but Brintellix is
selected. Consider implementing computer
alerts to warn about possible confusion.
Encourage prescribers to include the
medication’s generic and brand name and
indication on orders and prescriptions.
Store these drugs in separate locations
within the pharmacy.
Proper disposal of AUVI-Q (EPINEPHrine) autoinjector is critically important
(19)
Educate healthcare practitioners and
patients about the proper use and
disposal of the injector after replacing
the outer case. Confusion about the
ticking sound may cause patients to be
diverted to other facilities during
investigation of the noise and potentially
delay treatment.
Avoid using TPA or TNK when referring to ACTIVASE (alteplase) and TNKASE (tenecteplase)
The US Food and Drug Administration
Never use abbreviations for drug
(FDA) continues to receive reports of
names, including TPA, t-PA, or TNK.
October 8, 2015
ISMP MedicationSafetyAlert!

QAA 4
July – September 2015
ISMP
QuarterlyActionAgenda
Problem
Recommendation
mix-ups between Activase (alteplase)
and TNKase (tenecteplase) due to the
use of abbreviations, “t-PA” or “TPA.”
Nurses involved in these cases assumed
that t-PA was shorthand for TNKase
and attributed the errors to confusion
between TNK and TPA.
Instead, for alteplase and tenecteplase,
use the full drug names—brand,
generic, or both. Remove the
abbreviations from all order sets, order
entry screens, and treatment protocols.
Prescribers should state the indication
with orders to ensure the correct drug is
dispensed.
No.
Organization Assessment
Action Required/
Assignment
Date
Completed
Confusion between error-prone abbreviations for tranexamic acid (“TXA”) and tenecteplase (“TNK”)
(14)
(15)
A physician requested “TXA” for a trauma
patient who required tranexamic acid
(antifibrinolytic). The nurse thought he said
“TNK” and gave the physician
tenecteplase (thrombolytic) in a syringe.
Expecting an infusion, the physician
detected the error. If tenecteplase had
been given, the patient might have bled.
Both tranexamic acid and tenecteplase
may be in an automated dispensing
cabinet (ADC) in the emergency
department and available via override.
Do not use abbreviations for any drug
name, including “TXA” or “TNK.” Review
all forms of communication where these
drug names may be listed (e.g., drug
information resources, storage bin labels,
entries in ADCs and order entry systems)
and ensure that an abbreviation for either
name is not used. Consider including an
alert in order entry systems and ADC
databases that states the indications for
each drug and requires
acknowledgement prior to removal.
Engage pharmacy to ensure an independent double check of fluorouracil infusion rates
Over-infusion of fluorouracil has often
Ensure an independent double check of
been caused by accidental programming the infusion rate by engaging the help of
of the incorrect infusion rate, often by an
pharmacy. Pharmacy can set up the
oncology or home care nurse who may
pump and program the initial settings, and
not have a second healthcare
then hand off the pump and medication to
professional to verify the settings
the nurse, who then independently
independently.
verifies the patient’s identification and
compares what has been ordered against
the pump settings entered by the
pharmacist.
Methylene blue is a monoamine oxidase inhibitor (MAOI)
October 8, 2015
ISMP MedicationSafetyAlert!

QAA 5
July – September 2015
ISMP
Problem
Recommendation
A patient taking PARoxetine received
methylene blue during a procedure due to
the unavailability of the marker dye indigo
carmine. Methylene blue is a MAOI; as a
result of the interaction, the patient
required intubation and admission to the
intensive care unit. Methylene blue can
interact with selective serotonin reuptake
inhibitors and serotonin norepinephrine
reuptake inhibitors.
Facilities should treat methylene blue as
a medication and order the drug so it
can be verified/entered into the
pharmacy computer system to allow
potential drug interactions to be
identified. Practitioners without order
entry systems should incorporate drug
interaction checks for methylene blue
within existing processes.
No.
(19)
(19)
QuarterlyActionAgenda
Organization Assessment
Action Required/
Assignment
Date
Completed
Bendamustine (TREANDA) incompatible with some closed system transfer devices
A component of bendamustine, N,NDetermine if your facility uses a CSTD
dimethylacetamide (DMA), is
that is incompatible with bendamustine.
incompatible with closed system transfer
devices (CSTDs) that contain
polycarbonate or acrylonitrile butadiene
styrene (ABS). PhaSeal, a CSTD, does
not contain these components, and after
testing, it is confirmed that PhaSeal is
compatible with bendamustine.
October 8, 2015
ISMP MedicationSafetyAlert!

QAA 6