April – June 2014
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 April—June 2014 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 1
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/ActionAgenda1403.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 productrelated 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:
Problem
No.
(7)
(10)
—ISMP high-alert medication
Organization
Assessment
MARQIBO (vinCRIStine sulfate liposome injection) and conventional vinCRIStine mix-ups
Fatal mix-ups have occurred between
liposomal and conventional forms of drugs
(e.g., amphotericin B) due to vast dosing
differences. Such a mix-up is possible with
Marqibo and conventional vinCRIStine. A
pharmacist may receive an order for Marqibo
but dispense the conventional product, not
recognizing the higher dose recommendation
for the liposomal product. Also, Marqibo
requires a complex 26-step process for dose
preparation (www.ismp.org/sc?id=335).
Recommendation
Action Required/
Assignment
Date
Completed
Cover the differences between liposomal and
conventional products during staff orientation.
Orders for Marqibo are best communicated
using the proprietary and generic names,
indication for use, patient’s weight in kg, height
in cm, mg per m2 dose, and final dosage
calculation. Build dose-checking alerts in
computer systems for both formulations to
question all vinCRIStine doses that exceed
agreed upon dosing limits. Separate the
storage of Marquibo and conventional
vinCRIStine.
Administering just the diluent or one of two vaccine components leaves patients unprotected
When lyophilized vaccines are co-packaged
Educate staff about safety issues with twowith diluents, only the diluent may be
component vaccines and vaccines with
dispensed and administered by those who
diluents. Circle or highlight critical information
believe it is the actual vaccine. This error has
on vaccine containers or use flag-type labels
been reported most frequent-ly with ActHIB
without obscuring label information. If using a
(Haemophilus b conjugate) vaccine. Giving
vaccine that requires a specific diluent or two
just one part of a two-component vaccine is
components that must be combined before
another risk. This type of error has been
administration, keep the two vials together in a
reported most often with MENVEO
sealable plastic bag with a label reminder to
(meningococcal [groups A, C, Y, W-135]
use both vials. To confirm administration of
diphtheria conjugate) and PENTACEL
both vaccine components, document the NDC
(diphtheria and tetanus toxoids, acellular
number, lot number, and expiration date for
pertussis adsorbed, inactivated poliovirus and
each vial in the vaccine log before
Haemophilus b conjugate).
administration.
July 17, 2014
ISMP MedicationSafetyAlert!

QAA 1
April – June 2014
ISMP
Problem
No.
Organization
Assessment
ACTIQ (fentaNYL citrate oral transmucosal lozenge) mistaken as throat lozenge
(9)
Three providers ordered Actiq to treat a
sore throat, mistaking the powerful opioid
for a typical throat lozenge. All of the
patients were opioid naïve, but serious
harm was avoided when pharmacists
detected the error before dispensing the
product.
(11)
A patient experienced seizures and a cardiac
arrest after receiving magnesium sulfate
instead of 0.45% sodium chloride injection
with 20 mEq of potassium chloride. Pharmacy
had recently added 40 g magnesium sulfate
bags to an automated dispens-ing cabinet
(ADC) in an area that previously held bags of
0.45% sodium chloride injection with 20 mEq
of potassium chloride. The nurse had difficulty
reading the red-font labels through an
overwrap.
(12)
QuarterlyActionAgenda
Recommendation
Action Required/
Assignment
Date
Completed
Prescribing Actiq should be limited to pain
management specialists, anesthesiologists,
oncologists, palliative care, and hospice
providers who review an educational program
(www.ismp.org/sc? id=357) and complete a
knowledge assessment required by the drug’s
Risk Evaluation and Mitigation Strategy
(REMS).
Limit magnesium sulfate premix to 20 g bags
If needed, magnesium sulfate premixed
solutions should be stocked in units using the
20 g/500 mL bags, not the 40 g/1,000 mL
bags. The smaller volume helps limit the
amount of magnesium a patient might receive
if a rapid infusion occurs accidentally. In the
ED, hospitals may be able to stock only bags
intended for bolus doses (e.g., 2 g/50 mL, 4
g/100 mL). Some organizations use the 4 g
minibags for maintenance infusions.
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk
An ISMP survey of nearly 1,800 nurses found
Conduct a nursing survey to learn the extent
that most dilute certain IV push medications for and variability of dilution practices. Conduct
adults prior to administration. Even prefilled
educational programs to dispel myths and help
syringes con-taining a patient-specific dose are nurses see the risk associated with
diluted by almost a quarter of nurses.
unnecessary dilution. When possible, require
Unnecessary dilution often leads to unlabeled
pharmacy to prepare any IV push medications
or mislabeled syringes, potential conthat must be diluted according to the
tamination of sterile IV medications, dosing
manufacturer’s guidelines or hospital policy. If
errors, and other problems. Many nurses also
sta-bility requires dilution immediately prior to
reported the oft-unnecessary practice of
administration, provide directions for dilution
withdrawing a medication from a prefilled
via written or electronic guidelines or checklists
syringe and further diluting it in a larger syringe that provide standard diluent volumes and
for patients with an implanted port or a
concentrations.
peripherally inserted central catheter (PICC).
July 17, 2014
ISMP MedicationSafetyAlert!

QAA 2
April – June 2014
ISMP
No.
Problem
201
3:
Disrespectful behaviors in healthcare persist
uncheck-ed and are found at all levels of the
organization and among all disciplines.
According to ISMP’s 2013 survey, practitioners
frequently encounter disrespectful behaviors
that are clearly learned, tolerated, and
reinforced in a culture that considers a certain
degree of disrespect to be a “normal” style of
interaction. Productivity demands, cost
containment, and hierarchies that nurture a
sense of status and autonomy have been the
most influential factors. Disrespectful behaviors
cause the recipient to experience fear,
vulnerability, anger, humiliation, uncertainty,
and self-doubt. The behaviors erode
professional communication and collaboration,
and have been linked to adverse events, even
patient mortality.
(13,
20)
201
4:
(8)
(7)
Currently, Luer type connectors on medical
tubing, ports, and catheters have a universal
design that allows misconnections between
devices that serve completely different
functions (e.g., enteral tubing connected to a
tracheostomy tube inflatable cuff or an IV line).
Tubing misconnections are rare, but when
they occur, patient injuries can be serious, lifethreatening, and even fatal.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Disrespectful behaviors
Establish a committee and educate members
about the causes and impact of disrespectful
behavior. Encourage reporting of disrespectful
behaviors and establish a “no retribution”
policy for reporters. Create a code of conduct
or professionalism that serves as a model of
interdisciplinary collegial relationships and
collaboration. Establish a communication
strategy for staff who must convey important
information to enhance approachability and
reduce intimidating behaviors. Establish an
escalation policy to manage conflicts about the
safety of an order when the standard
communication process fails. Develop an
intervention policy that has leadership support
to consistently address disrespectful behavior.
New connectors coming for enteral feeding tubes
New enteral feeding device connectors that
will not allow connectivity to any other type of
connector will be introduced later this year.
New enteral-specific administration sets will be
available in the last quarter of 2014. Enteral
syringes for flushing and boluses will be
available with the new con-nector in the first
quarter of 2015, and new enteral feeding tubes
will be available in the second quarter. Visit
Stay Connected 2014 (www.staycon
nected2014.org) to prepare for these changes.
Guide patients to visit ConsumerMedSafety.org
July 17, 2014
ISMP MedicationSafetyAlert!

QAA 3
April – June 2014
ISMP
Problem
No.
(7)
Educating hospitalized patients about safe
medication practices can be a daunting task
given their short length of stay, limited attention
span when ill, and other health and safety
topics of importance that require patient
education. Because patients often seek
information about health and safety online,
hospitals can help patients reduce the risk of a
medication error by guiding patients to
reputable online resources.
(12)
Phenylephrine hydrochloride injection (10
mg/mL) 1 mL vials are often available for
emergency use. However, bolus doses (50250 mcg) cannot be drawn up accurately from
a 10 mg vial, and, therefore, dilution is
needed. Directions for dilution are not on the
label, and the package insert may not be
handy in an emergency.
(10)
(10)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Health systems with a website accessible to
patients should link to ISMP’s
ConsumerMedSafety.org, a user-friendly,
online resource that imparts knowledge about
safe medication practices in ways that
consumers can easily access, view, and use.
The real-world content can be searched by
topic or drug. Medication safety stories, overthe-counter medicine and insulin safety
sections, a medication safety toolbox, and a
consumer medication error-reporting system
are examples of the content areas.
Phenylephrine injection needs dilution for IV bolus
Create a dilution guideline or checklist for
this drug according to the package insert
for diluting 10 mg (1 mL) to yield a 100
mcg/mL concentration for bolus doses. If
possible, have pharmacy attend codes to
properly prepare this and other emergency
medications as needed for bolus dosing.
TASIGNA (nilotinib) label instructions may conflict with prescriber instructions
Confusion may lead to dosing errors with
ISMP informed FDA and Novartis about the
Tasigna because printed instructions on the
inci-dent and asked for removal of the dosing
manufacturer’s packaging reflect ONLY the
instructions from the blister packages. Prior to
recommended starting dose. One patient took patient discharge or dispensing a prescription,
two 200 mg capsules twice daily, as written on reinforce the correct dosing instructions and
the packaging, rather than once daily (400
tell the patient if it differs from what is
mg), as written on the prescription label. The
suggested on the blister pack. Give the patient
patient developed QT prolongation.
correct written instructions.
An order was placed for posaconazole 200 mg
PO TID with meals, but no dosage form was
July 17, 2014
Posaconazole (NOXAFIL) dose depends on dosage form
If both oral products (oral suspension,
delayed-release tablets) are available at
ISMP MedicationSafetyAlert!

QAA 4
April – June 2014
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
specified. The prescriber thought an oral
suspension would be used since, in the past,
that had been the only dosage form available.
In 2013, delayed-release tablets were made
available (and now there is an injectable form).
The order was transcribed as delayed-release
tablets. This is clinically relevant since the
delayed-release tablets have substantially
higher bioavailability than the oral suspension.
your institution, you may want to install a
clinical alert to appear at the time the drug
is ordered as a reminder of the various
dosage forms.
No.
Action Required/
Assignment
Date
Completed
Vancomycin injection for oral use given IM
Pharmacies should prepare the injectable
solution for oral use and provide each
individual dose in an oral syringe marked
“FOR ORAL USE ONLY.” Dispensing
medications in the most ready-toadminister form should be the prevailing
practice for all pharmacies that provide
medications in hospitals and LTC
facilities.
(12)
Due to the high cost of vancomycin capsules,
the injectable form of vancomycin powder is
often prepared as an oral solution to treat C.
difficile. In two long-term care (LTC) facilities,
the pharmacy provided vials of vancomycin
injection and diluent with directions for mixing
and administering each dose. Nurses were
unfamiliar with this practice and administered
each dose intramuscularly (IM), rendering it
ineffective to treat C. difficile.
(12)
When electronically prescribing Brintellix 10
mg daily for a patient with major depressive
disorder, a physician incorrectly selected
Brilinta, an antiplate-let agent. The patient
picked up the filled prescription but realized,
after reading an attached drug information
leaflet, that a mistake had been made.
If these drugs are available at your facility
or associated outpatient locations, take
steps to reduce the risk of confusion,
including building alerts to remind
prescribers to use generic names (in
addition to brand names) and list the
indication when prescribing these drugs.
(11)
Problems may arise during written or
electronic communication because of
similarities in appearance of the
alphanumeric symbols we use. For
example, the letter “l” can look like the
Misidentification of alphanumeric symbols
Promote visibility, legibility, and readability in
written communication using the following
methods: use lowercase or mixed-case letters
to provide distinction; encourage prescribers to
clearly print handwritten orders; provide lightly
BRINTELLIX (vortioxetine) and BRILINTA (ticagrelor) drug name confusion
July 17, 2014
ISMP MedicationSafetyAlert!

QAA 5
April – June 2014
ISMP
Problem
No.
numeral “1,” especially when the drug
name and dose are close together like
“Levoxyl25 mg.” There are similar issues
with other letters and numerals that share
similar characteristics.
July 17, 2014
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
lined order forms to prevent interference with
symbols; be selective about font and typeface;
avoid italics and underlining; and ensure
proper spacing between drug names and
doses, and between numerical doses and the
unit of measure.
ISMP MedicationSafetyAlert!

QAA 6