October – December 2013
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 October-December 2013 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’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). The Action Agenda is also available for download in a Microsoft Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1401.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. Many product-related
problems can also be viewed in the ISMP Medication Safety Alert! section of our website at: www.ismp.org. Continuing education credit is available for nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
—ISMP high-alert medication
Organization
Assessment
No.
Problem
(23)
More than 1,100 patients received less potent
chemotherapy than intended. Large bags of
chemotherapy had been prepared and
divided into smaller doses for multiple
patients. Overfill in the large bags was not
considered when listing the concentration on
the label because the compounding
pharmacy thought each large bag was to be
used as a single dose. Although the full dose
in each bag was listed on the label, the actual
concentration on the label was incorrect.
There are several methods that can be used
to prepare sterile products, each with specific
means for managing the overfill volume to
avoid confusion.
Understanding and managing IV container overfill
Choose the most appropriate method of
preparing each medication infusion according
to whether or not the volume/concentration is
critical. Obtain a list of overfill amounts of
commonly used products from vendors for
reference as necessary. For continuous
infusions titrated to effect, ensure
standardization in the preparation process in
order to avoid variations in concentration and
inconsistencies with the dose delivered. For a
single dose drug infusion, the most critical
aspect of the process is ensuring that the entire
contents in the container are administered; the
label should include a reminder, “Infuse entire
contents for full dose.”
(22)
As the use of U-500 insulin grows, so do the
number of errors, mostly related to dosing
confusion caused by not having a syringe
with a U-500 scale. Healthcare providers and
patients rely on syringes meant for U-100
insulin to measure U-500 insulin doses. This
results in communicating the dose by the
number of units that correspond to the U-100
syringe. Another source of confusion is name
similarity since HUMULIN R is the name
used for both U-100 insulin and U-500
insulin.
Safety concerns surrounding the use of U-500 insulin
Until U-500 syringes or pens are available,
use tuberculin syringes to measure doses
by volume, using a dosing conversion
chart (available at:
www.ismp.org/sc?id=260). Total doses
should be expressed in both units and
volume (i.e., 200 units [0.4 mL]). To
minimize name confusion, ensure the
strength is listed with each HUMULIN R
insulin product during order entry.
Separate U-100 insulin and U-500 insulin
vials in storage areas.
January 30, 2014
Recommendation
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 1
October - December 2013
ISMP
Problem
No.
(23)
(25)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Initiative to eliminate tubing misconnections
Catheter misconnections happen when tubing A phased-in approach to launch the new
from one type of delivery system is connected connectors, starting with enteral devices, will
to another delivery system that serves a
occur in 2014. Organizations should review
different function. An international effort is
the publication, Stay Connected, for
underway to standardize the various types of
Frequently Asked Questions
connectors used in healthcare, making them
(www.ismp.org/sc?id=267) and to begin the
incompatible with each other.
initial steps to prepare for these changes.
10 mL syringes for medication administration via venous access devices not needed
Some nurses erroneously believe that a 10 mL While smaller diameter syringes create
syringe (or 10 mL diameter equivalent) is
greater amounts of pressure than larger
needed to administer IV medications via
diameter syringes, the Infusion Nurses
venous access devices (VAD). This has led to Society (INS) recommends flushing a VAD
nurses emptying the contents of medications
using a 10 mL syringe to assess patency.
in smaller, prefilled 10 mL syringes into larger
Thus, once patency is assured, medication
syringes. This practice does not allow bedside administration in a smaller syringe is
barcode scanning of the medication syringe
acceptable. One of the largest
and can lead to partial loss of a dose,
manufacturers of IV access devices, Bard,
contamination of the solution, inaccurate
will be changing product labeling to clarify
measurement of small doses, and unlabeled
this issue.
syringes.
(21)
To function at its full, safe potential, smart
infusion pumps require entry of dose limit
settings in their libraries for each high-alert
IV medication infused by the pump. This
can be a complex, time-consuming, and
error-prone task. Individual hospital efforts
also suggest wide variability in how the
dose limits are expressed.
(20)
A nurse accidentally injected a hepatitis C
positive patient with an empty insulin
syringe before she realized she hadn’t
filled it with insulin. She then used the
same syringe and needle to withdraw
insulin from a vial. That vial was later used
January 30, 2014
Toolkit for smart pump dose limits
The San Diego Patient Safety Council posted
a toolkit (www.ismp.org/sc?id=255) to provide
evidenced-based recommendations and best
practices for establishing and managing highalert IV medication dose limit settings. The kit
provides drug-specific recommendations for
implementing dosing limits in your institution.
Possible cross-contamination with insulin vials
Using 3 mL insulin vials would expose
fewer patients if the vial becomes
contaminated. Where possible, preparation
of patient-specific insulin doses by
pharmacy would greatly reduce the risk of
cross-contamination.
ISMP MedicationSafetyAlert!

QAA 2
October - December 2013
ISMP
Problem
No.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
to prepare doses for other patients,
exposing more than 70 patients to hepatitis
C.
(21)
A pharmacy found a box of RabAvert with the
diluent vial but not the actual vaccine powder.
This could have resulted in an ineffective
vaccination if only the diluent was
administered. The diluent and vaccine vials
are both packaged in small vials with similar
green labels and caps. A fatal outcome is
almost certain in people infected with rabies
virus who do not receive post-exposure
vaccination.
(21)
A pharmacy inadvertently dispensed an
entire 1 mL vial of tuberculin 5 units/0.1 mL
(10 doses) as a single dose. Only on the
front of the vial’s label does it state 5
units/0.1 mL. The vial must be turned to see
the notation of 10 doses per vial.
(23)
A nurse needed to administer ciprofloxacin
but could not find the drug in the smart pump’s
library. Fortunately, she did not simply
override the dose-checking function and
administer the drug. Follow-up showed the
pump belonged to another hospital and was
brought into the facility during a patient
transfer. The two pumps looked identical, with
the only difference being the respective
organizations’ name displayed on the very
top of the screen.
January 30, 2014
RABAVERT (rabies vaccine) diluent could be mistaken as vaccine
We have contacted Novartis to request
improvements to the packaging. Hospitals
may want to consider purchasing IMOVAX,
a rabies vaccine produced by another
company, which is presented in a sealed
tray that holds a prefilled diluent syringe for
reconstitution of the vaccine.
Tuberculin purified protein derivative (PPD) label confusion
All PPD doses should be dispensed from
the pharmacy in unit-dose, intradermal
syringes containing the proper dose.
Infusion pump with library from different hospital
Establish procedures outlining how to handle
infusion pumps (and other equipment) during
patient transfer. Consider applying a large,
auxiliary label with your hospital’s name on all
pumps that are owned. If rental pumps are
used, they should arrive at the hospital with a
blank library. If not, have the library removed
immediately by biomedical engineering. The
hospital-specific library should be loaded prior
to use.
ISMP MedicationSafetyAlert!

QAA 3
October - December 2013
ISMP
No.
Problem
(23)
The recommended dose of Spiriva is 2
inhalations of the powder contents of 1
capsule. Many order entry systems will default
to a dose of 1 inhalation, and if this is changed
to 2 inhalations, it may result in the patient
receiving the contents of 2 capsules. If the
dose is entered as 1 capsule, the patient may
receive the product orally.
(24)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Potential dose confusion with SPIRIVA (tiotropium)
Make sure Spiriva dosing is expressed clearly
in your order entry system to avoid
administering the wrong dose or via the wrong
route. Express the dose in a manner that
lessens the risk of confusion (e.g., 1 capsule =
2 inhalations). Ensure the patient understands
how to properly use the medication (and
inhalation device).
Caution with Demo-Dose products (demonstration only) from Pocket Nurse
A demo product for EPINEPHrine injection If your education department, simulation
emergency syringes (Pocket Nurse) was
lab, or associated nursing school is using
found in a code cart. The demo product
these or other demo products, be sure they
looks nearly identical to syringes
are strictly limited to classroom use.
(Abboject) from Hospira that contain the
Instructors should account for each demo
actual drug. The Demo-Dose product is
product at the end of class to ensure they
sold for use during simulation training. Had don’t inadvertently reach a patient care
these remained in the cart, they could have area.
been injected during a code or delayed
emergency treatment. Also, the distilled
water in these demo syringes is not sterile.
(22)
An independent double-check cannot be
performed for selected high-alert
medications while working alone.
(24)
As the US Food and Drug Administration
Performing a cognitive check while working alone
Perform a cognitive check (left brain, right
brain) if working alone by holding the
container in one hand while reading the label
aloud, and then switching hands and reading
it aloud again.
AVANDIA (rosiglitazone) and COUMADIN (warfarin) mix-ups with handwritten orders
January 30, 2014
Most physician practices and many hospitals
ISMP MedicationSafetyAlert!

QAA 4
October - December 2013
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
(FDA) lifts some of the restrictions previously in
place with Avandia, the drug’s use may rise.
Practitioners may not remember that Avandia
and Coumadin were one of the most
commonly reported serious drug name mixups in the past with handwritten orders.
that are now utilizing electronic prescribing
systems will not see this error. However, if the
use of Avandia is being contemplated in the
future, the potential for drug name mix-ups
with handwritten prescriptions should be
considered and addressed.
(22)
Errors are possible because apothecary
strengths such as “gr” (grains) are still
used for certain drugs such as ferrous
sulfate and PHENobarbital. Grains (gr)
could be confused with grams (g).
Apothecary strengths confused
Consider purchasing products from
manufacturers that do not use apothecary
strengths on labels to minimize the risk of
confusion. If this is not pos-sible, ensure that
pharmacy labels for these products do not
contain apothecary strengths.
(24)
An immunization-certified pharmacist was
not aware that all influenza vaccine
products had to be shaken before use. The
vaccine cartons are labeled “shake well.”
But the vial and syringe labels of influenza
vaccine that we’ve looked at are not so
labeled.
(23)
Mix-ups have been reported between
Cardizem and Cardene. In one case, an
emergency department nurse prepared
and administered a Cardene infusion
instead of a Cardizem infusion. In another
case, a nurse programmed a smart pump
to infuse Cardizem instead of Cardene.
The patient received the correct drug at the
wrong infusion rate.
No.
January 30, 2014
Action Required/
Assignment
Date
Completed
Influenza vaccine–shake well!
Ensure staff who vaccinate patients with
the flu vaccine are aware that all influenza
vaccines, including FLUBLOK (which is a
solution, not a suspension), need to be
shaken before use, whether packaged in a
single dose or multiple dose vial, or a
prefilled syringe.
CARDIZEM (diltiazem) and CARDENE (niCARdipine) mix-ups
Change the appearance of these drug names
on computer screens, pump display screens,
storage areas (including automated
dispensing cabinets), pharmacy product
labels, and medication administration records
(MARs), using bold face, color, or tall man
letters for the parts of the names that are
different. Configure computer/pump screens
to prevent look-alike drug name pairs from
appearing consecutively. Be sure mnemonics
for either of these drugs is not simply C-A-RD.
ISMP MedicationSafetyAlert!

QAA 5
October - December 2013
ISMP
No.
January 30, 2014
Problem
QuarterlyActionAgenda
Organization
Assessment
Recommendation
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 6