May - August 2012
ISMP
AmbulatoryCare ActionAgenda
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. To promotesuch aprocess,
thefollowing selected agendaitems havebeen prepared for you and your staff tostimulatediscussion and collaborativeaction toreducetherisk of medication errors. Theseagendatopics appeared in theISMPMedication Safety Alert!
Community/Ambulatory CareEdition between May 2012 and August 2012. Each itemincludes abrief description of themedication safety problem, recommendations toreducetherisk of errors, and theissuetolocateadditional information. TheAction
Agendais alsoavailablefor download in aWord format (www.ismp.org/Newsletters/ambulatory/Issues/ActionAgenda201209.doc). Tolearn howtousetheISMPAmbulatory CareAction Agendaat your practice site, visit
www.ismp.org/newsletters/ambulatory/How_To_Use_AA.asp.
No.
Problem
08/1
2
A community pharmacist
inadvertently dispensed
methadone to a 7-year-old boy
who normally takes
methylphenidate 10 mg BID. The
child became lethargic and
vomited after taking one dose,
and the same symptoms
occurred after giving the child the
same dose a second time the
following day. ISMP and the US
Food and Drug Administration
(FDA) have received multiple
reports of confusion between
methadone and
methylphenidate.
07/1
2
We received yet another report
of a mix-up between
risperiDONE (RISPERDAL) and
rOPINIRole (REQUIP). A patient
experienced nausea and an
unexpected sedative effect after
taking what was thought to be
risperiDONE. It was discovered
that rOPINIRole tablets had been
dispensed in error. As in earlier
cases, the products were from
the same manufacturer in the
same shaped bottle with similar
printing.
September 2012
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Methadone or methylphenidate?
Configure mnemonics in e-prescribing
and pharmacy order entry systems to
warn about confusion between
methadone and other drugs that start
with “meth” and have similar
strengths. Separate methylphenidate
and methadone in storage areas.
Barcode scanning during the
production stage of the dispensing
process can identify when the wrong
product is selected from the shelf.
Identify barriers to successful
scanning in order to minimize the risk
of bypassing or overriding the scan of
the product barcode.
Mix-ups between risperiDONE and rOPINIRole
The US Food and Drug
Administration has asked
manufacturers to use tall man
lettering on container and carton
labels. When prescribing either drug,
the drug name should be printed and
the purpose of the drug should be
included on the prescription. In
pharmacies, do not store the products
near one another, and use tall man
letters for storage labeling and
computer listings. Implementing
barcode scanning during the
production stage of the dispensing
process can identify wrong product
selection from the shelf.
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 1
May-August 2012
ISMP
No.
Problem
06/1
2
Upon listening to the pharmacy’s
voice mail system, a licensed
pharmacy intern questioned a
prescription that sounded like
“zolpidem 100 mg, take 4 tablets
by mouth once daily.” The
physician was contacted and
intended for the patient to
receive ZYLOPRIM (allopurinol)
for gout.
05/1
2
An outreach worker visited the
home of a patient with active
tuberculosis to give a dose of
isoniazid to the patient’s children.
One of the children vomited after
receiving one-half of the dose.
The syringe containing the
remainder of the dose was
placed on a table while the child
was cleaned. A sibling, who had
already received his dose of
medication, picked up the
unsecured syringe and ingested
the remainder of the medication.
As a result, the child received
approximately 800 mg of
isoniazid in total.
07/1
2
Although medication samples
may seem to help with the high
cost of medications, there are
many safety issues. First, they
may be expired due to the lack of
regular office staff audits, poor
organization and inventory
control, and storage space.
September 2012
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Say what? ZYLOPRIM or zolpidem?
Pharmacies should record information
on their voice mail messaging system
prompting prescribers to spell out the
drug name and sound out the dose
(e.g., one-five instead of fifteen),
provide the indication, and use both
brand and generic names when
prescribing these drugs.
Preventing unintentional mediation overdoses
Keep all medications secured and out
of the reach and sight of children,
even when the caregiver is in the
same area as the child. Teach
children about medication safety, and
tell them what medicine is and why
their parent or caregiver must be the
one to give it to them. For more
information and strategies to protect
children from unintentional medication
overdoses, visit the Up and Away and
Out of Sight educational campaign at:
www.upandaway.org.
Medication samples and safety concerns for physician practices
Store medication samples in
accordance with manufacturers’
labeling and in locked cabinets away
from patient and staff traffic. Establish
policies that indicate who is
responsible to monitor storage,
inspect for outdated product, maintain
the sample medication log, and
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 2
May-August 2012
ISMP
AmbulatoryCare ActionAgenda
Problem
Recommendation
Second, samples are distributed
without safety checks that exist
in pharmacies (e.g., computer
screening for drug interactions,
duplicate therapy, and
contraindications). Lastly, patient
education may be limited or
narrow in scope and the samples
may have problematic or
confusing labeling.
ensure safety measures are followed.
Medication samples should be treated
like new prescriptions with respect to
screening for drug interactions,
duplicate therapy, allergies, and
contraindications. Pharmacists might
be able to offer a consulting service to
area physicians where they review
office medication storage at regular
intervals.
No.
06/1
2
A mix-up of Sig codes was
believed to be a cause for an
error. During review of a refill for
HYDROcodone and
acetaminophen 5 mg / 500 mg,
the directions printed on a label
were “Test 4 times daily” instead
of “Take 4 tablets daily.” The
patient had been receiving the
dosage for over a year so he
continued to take the prescription
correctly. The pharmacy’s
investigation showed that the Sig
code “T4TD” was used instead of
“T4TDA,” which corresponded to
the correct directions.
08/1
2
The manufacturer has halted
distribution of individual EPIPEN
(EPINEPHrine) 0.3 mg AutoInjectors and only distributes an
EpiPen 2-Pak. The 2-Pak
contains two EpiPens plus a
training pen. The training pen,
which looks like a real EpiPen,
was found stored in the EpiPen
drawer in an Emergency
Department’s automated
September 2012
Organization Assessment
Action Required/
Assignment
Date Completed
Sig code shortcut to error
Run reports of system Sig codes that
are in use. These Sig codes should
be evaluated and those that are at
risk for causing an error should be
removed. Furthermore, at the pointof-sale, pharmacy staff should review
each prescription container with the
patient, whether it is a new
prescription or refill, by opening up
the bag and prescription container.
EpiPen 2-Pak plus training pen confusion
Instruct patients and parents to
separate training pens from the real
thing and make sure that only the
actual EpiPen is sent with children
when they go back to school. Please
be sure staff know about the risk of
confusion between the training pen
and actual pen. Long term care
facilities should unpack the pens and
store only the active pens in ADCs.
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 3
May-August 2012
ISMP
Problem
No.
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
dispensing cabinet (ADC).
07/1
2
A nurse gave a patient 5 drams
of acetaminophen concentrate
liquid (100 mg/mL) instead of 5
mL. That’s equivalent to 18.45
mL, or 1.845 g of
acetaminophen. The dose was
measured in a dose cup with
scales that measure in drams,
fluid ounces, cc, mL, TSP, and
TBSP. Also, the hospital was
using concentrated
acetaminophen instead of the
new standard strength (160 mg/5
mL).
08/1
2
The Centers for Disease Control
and Prevention has made a
toolkit available to help educate
healthcare providers and
patients about safe injection
practices. Any healthcare
provider that gives injections
should be aware of safe injection
practices.
08/1
2
Keeping an up-to-date list of
medications will help patients
remember all the medications
they are taking. Patients can
share the list with doctors,
hospital staff, and pharmacists,
to help protect against mistakes.
06/1
2
ISMP has redesigned its
medication safety website for
consumers
(www.consumermedsafety.org).
There are many useful
medication safety tools and
resources available.
September 2012
Archaic liquid measure a factor in medication errors
Facilties should check supplies and
remove measuring devices with
archaic measurement scales.
Pharmacists that serve a nursing
home or other care facility, make sure
these aren't in use. Also, pharmacists
should not sell cups with archaic
measurements. For liquid
medications, oral syringes should be
used instead of dose cups. Remove
any concentrated acetaminophen
from your supplies.
Safe injection toolkit available
The toolkit contains audio-visual and
print materials that can be distributed
at staff meetings, incorporated into inservice education, and posted in
public areas. To access the toolkit,
visit:
www.oneandonlycampaign.org/conte
nt/healthcareprovider-toolkit.
Help your patients keep an up-to-date list of medications
ISMP has developed a Personal
Medicine Form, available at:
www.ismp.org/Tools/personal_med_f
orm. Please share the form with your
patients.
ISMP consumer website updated
Consider how the website might
benefit your patients. Please help
ISMP promote the website by sharing
the link in consumer information that
you provide. Please also include the
link on your website.
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 4
May-August 2012
ISMP
September 2012
AmbulatoryCare ActionAgenda
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 5