July – September 2010
ISMP
QuarterlyActionAgenda
One of themost important ways toprevent medication errors is tolearn about problems that have occurred in other organizations and tousethat information toprevent similar problems at your practicesite. To promotesuch
aprocess, thefollowing selected items fromtheJuly-September 2010 issues of theISMPMedication Safety Alert! have been prepared for an interdisciplinary committeeto stimulate discussion and action to reduce therisk of
medication errors. Each itemincludes a description of themedication safety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional information as desired. Look for our high-alert
medication icon under theissue number if the agendaiteminvolves one or moremedications on the ISMPList of High-Alert Medications. TheAction Agendais also availablefor download in aWord format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1004.doc) that allows expansion of thecolumns in thetabledesignated for organizational documentation of an assessment, actions required, and assignments for each agenda
item. Many product-related problems can also beviewed in the ISMPMedication Safety Alert! section of our website at: www.ismp.org. Continuing education credit is availablefor nurses at:
www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
—ISMP high-alert medication
Special Note: Problems associated with drug shortages and theCenters for Medicare&Medicaid Services 30-minuterulewill becovered in our next Quarterly Action Agenda, after wehavepublished recommendations related tothesetopics.Key:
No.
Problem
(13)
The ISMP Medication Errors
Reporting Program (MERP)
database contains hundreds
of cases of mix-ups between
adult and pediatric products
used to immunize patients
against diphtheria, tetanus,
and pertussis. These products
are easy to confuse due to
their similar names and
abbreviations (DTaP-Tdap).
An infant/child who receives
Tdap instead of DTaP would
receive an inadequate dose of
antigen.
(14)
Catheter/tubing
misconnections remain a
serious problem in healthcare.
Luer connector systems,
common to many healthcare
catheters, tubes, and
syringes, pose the greatest
risk.
April 19, 2007
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
DTaP-Tdap mix-ups now affecting hundreds of patients
Educate staff about the risk of
confusion. Separate the pediatric
and adult formulations in storage
areas. Encourage prescribers to
order the vaccines by brand name,
not vaccine abbreviation. Document
the vaccine and lot number on the
vaccine form/log just prior to
administration (document
administration after the vaccine has
been given). Ask parents or
caregivers to assist with verification
of the vaccine before it’s
administered.
Preventing catheter/tubing misconnections
Perform a risk assessment to identify
the various types of catheters and
fittings in use, the possibility for
misconnections, the potential
severity of misconnections, and
process changes that need to be
made. Always trace the port and
tubing back to its insertion site, and
never attempt to force a connection
that does not fit easily and securely
ISMP MedicationSafetyAlert!

QAA 1
July – September 2010
ISMP
Problem
No.
(13)
Two fatalities occurred due to
IV admixture errors that were
not detected during the
checking process. Checks
performed after manual IV
admixture preparation often
involve the “syringe pullback”
method, which is less than
ideal. This type of error-prone
check is based on the
preparer’s memory of how
much drug was added to the
bag and proper placement of
the syringe next to the used
product in crowded spaces.
(15)
Although rare, serious and
fatal (one death of a 22-yearold) air or gas embolisms
have occurred during or
immediately after application
of fibrin sealants using air- or
gas-pressurized sprayers. In
some cases, the devices were
used at a higher than
recommended pressure or at
a distance too close to the
surface of the bleeding site.
October 10, 2010
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
into an access port. For additional
recommendations to avoid
catheter/tubing misconnections, visit:
www.ismp.org/sc?k=enteraladminsaf
ety. The International Organization
for Standardization (ISO) has been
working on a standard that will make
various healthcare catheter fittings
and associated tubing sets or
syringes incompatible with one
another.
Post-production IV admixture checks less than ideal
Utilize commercially available or
outsourced premixed products
whenever possible. When pharmacy
admixture is required, products with
a high-alert medication should
employ an independent doublecheck of the vials, prepared
syringes, and container labels prior
to adding it to the solution. IV robotic
preparation systems and
commercially available workflow
management systems also can
decrease error potential.
Air embolism risk with pressurized sprayers
Educate surgical staff about this risk
and proper use of the product. Use
the applicator, spray set, and
pressure control device or regulator
as noted in the labeling. Use an airor gas-pressure setting within the
range recommended by the
manufacturer. Ensure that the
distance between the spray head
and the tissue is at or above the
minimum recommended by the
manufacturer.
ISMP MedicationSafetyAlert!

QAA 2
July – September 2010
ISMP
No.
Problem
(16)
Warning statements can be
overlooked or misread
depending on how they are
presented. Negative and
passive words in warning
statements require more effort
to interpret correctly. Thus, a
healthcare provider under
stress may fail to process the
negative parts of the
warning—such as “Do Not”—
and misinterpret the warning
as an affirmative action.
(16)
If niMODipine must be
administered through a
feeding tube, FDA
recommends puncturing the
capsule with an 18 gauge
needle, extracting the liquid
contents with a parenteral
syringe labeled “Not for IV
Use.” However, this may
result in accidental IV
administration, particularly if
only the “…IV Use” portion of
the label is read.
(17)
The 1 mL vials of American
Regent’s vasopressin injection
(20 units/mL) and atropine
sulfate injection (0.4 mg/mL)
look very similar because the
font style and color used on
the labels and caps are nearly
identical.
(17)
Adding a drug to a hanging IV
October 10, 2010
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Utilize affirmative warning statements instead of negative warning statements
Date Completed
Utilize affirmative warning
statements (e.g., “IM use only”
instead of “Not for IV use”) in an
active voice to facilitate
comprehension and compliance. Use
a signal word: Danger for immediate,
potentially deadly hazards; Warning
for unsafe practices that may cause
injury; Caution for hazards that can
cause minor injury. The warning that
follows should be explicit.
Preparation of liquid niMODipine
Liquid niMODipine should be
prepared ONLY in the pharmacy and
be dispensed ONLY in an oral
syringe labeled “WARNING: For Oral
Use Only.” Outsourcing the
preparation of liquid niMODipine
from a reliable compounding
pharmacy is also an option.
Confusion between American Regent’s vasopressin and atropine sulfate injections
Purchase one of the products from a
different manufacturer to help
distinguish the two. At a minimum,
the products should be stored in
separate locations whenever
possible.
Do not add drugs to hanging IV bags
Create and enforce a policy
ISMP MedicationSafetyAlert!

QAA 3
July – September 2010
ISMP
Problem
No.
bag poses many risks,
including: infection control;
drug incompatibilities;
inadequate mixing to gain
uniform concentration of the
drug in solution; drug pooling
at the spiked end of the bag or
bottle, putting patients at risk
of a potential overdose; label
inaccuracies related to the
actual concentration of the
drug that is in the solution.
(13)
A physician ordered caffeine
500 mg IV, intending for the
patient to receive 500 mg of
caffeine and sodium
benzoate, not 500 mg of the
caffeine moeity. The nurse
based the dose on the
caffeine component, which is
prominent on the label and
states that each vial contains
125 mg/mL of the caffeine
moiety (250 mg caffeine total).
The nurse used four vials to
prepare the dose, so the
patient actually received 1
gram of caffeine and sodium
benzoate instead of the
intended 500 mg.
(17)
While using an electronic
prescribing system, a
physician ordered 9 mg/kg of
panitumumab (VECTIBIX) IV
every 3 weeks for an adult
patient. The physician
inadvertently entered the
patient’s height (cm) as the
October 10, 2010
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
prohibiting the addition of
medications to hanging parenteral
nutrition solutions or IV solutions of
any type.
American Regent caffeine and sodium benzoate injection dose confusion
Alert staff that dosing confusion has
been linked to the label of the
recently revised American Regent
product. Prescribers should specify
whether the dose is based on the
combination of components or just
the dose of the caffeine. If not, clarify
the order.
Height and weight mix-up with electronic prescribing
When possible, set protocol-based
maximum doses in prescribing and
pharmacy computer systems that
require a reason for overriding an
alert. Monitor the electronic alert
system to minimize the number of
low-priority alerts, and test for
inclusion of high-priority alerts. Form
ISMP MedicationSafetyAlert!

QAA 4
July – September 2010
ISMP
Problem
No.
weight, and the weight (kg) as
the height. The patient
received 650 mg more
panitumumab than intended.
(13)
&
(18)
(15)
(19)
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
an interdisciplinary team to identify
how existing double-checks are
being conducted.
Methylene blue overdose risk
Methylene blue is used as an
Ensure your computer system does
antidote for drug-induced
not default to mL dosing for
methemoglobinemia.
methylene blue. Educate prescribers
Accidental overdoses of
to only order the medication in mg.
methylene blue occur
Consider adding a maximum weightoccasionally; the patient could based dose of 2.5 mg/kg to your
turn blue, which can be
pharmacy computer system for
mistaken for cyanosis. Dosing methylene blue to further protect
errors are possible if the mg
against accidental overdoses.
dose is accidentally
prescribed as mL, or if the
computer system lists the
dose of methylene blue in mL.
Sound-alike names: FLUoxetine and PARoxetine, XANAX (ALPRAZolam) and FANAPT (iloperidone)
An 8-year-old child with
Use both the brand and generic
anxiety and depression
names when prescribing lookincorrectly received
alike/sound-alike drugs. Names on
PARoxetine 10 mg instead of
your look- and sound-alike list should
FLUoxetine 10 mg when a
be spelled back to the prescriber
telephoned prescription was
during read-back of a telephone or
misheard. A nurse misheard
oral order. Ensure that a process
the order for the new
exists to educate professional staff
antipsychotic Fanapt as
about new medications before they
Xanax, which are both
are added to the formulary and
available as 1 and 2 mg oral
prescribed.
tablets; it is likely that
confirmation bias (hearing the
familiar drug name)
contributed to the mix-up.
DORIBAX (doripenem) and ZOVIRAX (acyclovir) name confusion
A unit secretary incorrectly
Due to confirmation bias and
interpreted a handwritten
frequent interruptions, weigh the risk
physician order for Doribax
of unit secretaries entering
and entered Zovirax 500 mg
medication orders. Also, due to
October 10, 2010
ISMP MedicationSafetyAlert!

QAA 5
July – September 2010
ISMP
Problem
No.
IV q8h. Although the dose
appeared to be appropriate for
Zovirax, the order was written
by a pulmonologist, which
seemed unusual and
prompted a pharmacist to
clarify and correct the order
transcription.
(13)
The word biweekly usually
means once every 2 weeks,
but it can also mean twice-aweek. The word bimonthly
usually means once every 2
months; however, it can also
indicate twice a month. An
order written for chlorambucil
to be given “BIW” (intended
meaning: biweekly or twice-aweek) was misinterpreted as
“twice daily.”
October 10, 2010
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
potential carbapenem resistance,
limit the prescribing of Doribax to
infectious disease physicians.
Educate staff about the confusion
between these two drug names.
“Biweekly,” “BIW,” and “bimonthly” confusion
Avoid “biweekly” (including the
abbreviation BIW) and bimonthly
when ordering medications. Instead,
use terms such as “twice-a-week,”
“every other week” (or “every 2
weeks”), or “every other month” (or
“alternate months”)
ISMP MedicationSafetyAlert!

QAA 6