January – April 2014
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 the ISMPMedication Safety Alert!
Community/Ambulatory CareEdition between January 2014 and April 2014. Each itemincludes abrief description of themedication safety problem, recommendations toreducetherisk of errors, and theissuetolocateadditional information. TheAction
Agendais alsoavailablefor download in aWord format at: www.ismp.org/Newsletters/ambulatory/actionagenda.asp. Tolearn howtousetheISMPAmbulatory Care Action Agendaat your practicesite, visit
www.ismp.org/newsletters/ambulatory/How_To_Use_AA.asp.
No.
Problem
03/1
4
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 U500 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.
03/1
4
An opioid-naïve 89-year-old
woman, who was enrolled in a
home hospice program, was
prescribed fentaNYL
transdermal system
25 mcg/hr patch for pain
management, even though
she was opioid naïve with her
pain previously controlled with
acetaminophen and locallyapplied heat. Although, this
patient was enrolled in
hospice, fentaNYL
transdermal system is not
indicated for opioid-naïve
patients.
May 2014
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Safety concerns with U-500 insulin
Until U-500 syringes or pens are
available, use tuberculin syringes
when possible 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
concentration is listed with each
HUMULIN R insulin product during
order entry. Separate U-100 insulin
and U-500 insulin vials in storage
areas.
Opioid safety with DURAGESIC (fentaNYL transdermal)
Prescribers must consider the
prescribing information before
initiating fentaNYL transdermal
therapy. Before dispensing or
administering the medication,
pharmacists and nurses must
ensure that a fentaNYL patch, and
dose prescribed, is appropriate for
the patient, and that the patient
and/or caregiver received
complete education regarding
safe and proper use of the patch.
If the patient is a first time user
and/or opioid-naïve the prescriber
should be contacted to review
prescribing information and
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 1
January – April 2014
ISMP
Problem
No.
01/1
4
12/1
3
04/1
4
03/1
4
One-year-old twins who were
prescribed lidocaine viscous 2%
for teething pain developed
seizures and cardiac arrest. Toxic
lidocaine blood levels were
identified in both infants. Toxicity
can occur with this and
benzocaine-containing products
used for teething pain.
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
discuss other treatment options.
Topical anesthetics for teething infants
The American Academy of Pediatrics
discourages topical anesthetic use for
teething pain, and viscous lidocaine is
not FDA-approved for this purpose.
Teach parents to avoid these products
and to use safer alternatives including
teething rings and pain medications,
such as acetaminophen and ibuprofen
per directions from a healthcare
professional.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors
Analysis of data submitted to the
Make easy-to-read immunization
ISMP National Vaccine Errors
schedules available in clinical areas.
Reporting Program (ISMP VERP) Provide patients/parents with a
identified the vaccinations most
Vaccine Information Statement (VIS)
frequently associated with
to read before administering the
errors—influenza, Hib, DTaPvaccine. Establish protocols for
IPV, Tdap, DTaP, HepA, and
frequently administered vaccines.
HepB. Analysis also identified the Separate pediatric and adult
most common contributing
formulations, and affix auxiliary labels.
factors—choosing among ageAvoid the practice of drawing vaccines
dependent formulations of the
into syringes well in advance of
same vaccine; unfamiliarity with
administration. Ask the patient/parent
combination vaccines; failure to
to verify the vaccine information on
verify the patient’s age; similar
the immunization record. Label all
vaccine names and
prepared syringes, and use full
abbreviations; similar and
vaccine names or CDC standard
confusing labeling and
abbreviations.
packaging; and unsafe storage
conditions.
The Diastat AcuDial delivery
system is available in 10 mg or
20 mg rectal syringes designed to
deliver minimum dosages of 5
mg or 12.5 mg, respectively, with
dosage increments of 2.5 mg up
May 2014
DIASTAT ACUDIAL (diazepam rectal gel) requires setting and locking of the dose
Teach each pharmacist how to dial,
set, and lock the dose of Diastat
AcuDial rectal syringe. Consider
building an alert into the pharmacy
computer system to notify the
pharmacist that the dose must be
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 2
January – April 2014
ISMP
AmbulatoryCare ActionAgenda
Problem
Recommendation
to a maximum of either 10 mg or
20 mg. In a case reported to
ISMP, a patient’s prescribed dose
was 15 mg, but the pharmacist
mistakenly locked the dose at 20
mg. The patient’s parent did not
discover the error until after she
had administered the dose.
dialed and locked. Incorporate an
independent double-check with a
second pharmacist or pharmacy
technician before the dose is locked to
check that the correct dose has been
selected. At the point-of-sale, have the
patient or caregiver check each
syringe to ensure the correct dose has
been locked.
No.
01/1
4
A patient came to the community
pharmacy to pick up a
prescription; however, the
patient’s bag could not be
located. The pharmacy computer
system confirmed the prescription
had been filled. Pharmacy staff
then checked all the bags in the
will-call area. The patient’s
medication was found in another
patient’s bag. Both patients had
the same last name.
03/1
4
If a drug is not covered by a
patient’s insurance provider,
some ambulatory electronic
health record (EHR) systems
(e.g., Epic IT vendor) may
provide a list of “alternative”
medications. But the
“alternatives” may not be
appropriate. For example,
cloNIDine (listed as an analgesic
adjuvant drug) was
recommended as a substitute for
acetaminophen, and
ALPRAZolam was listed as an
May 2014
Organization Assessment
Action Required/
Assignment
Date Completed
Review your “bagging” procedures
Consider using baskets or trays to
keep labeled containers and receipts
for one patient together through the
production process until final
verification. Staff should consistently
use 2 patient identifiers at the point-ofsale to catch any bagging errors that
make it to the will-call area. Compare
patient responses to the information
listed in the computer system or
printed on the prescription receipt and
vial. Staff should check each vial at
the point-of-sale and present it to the
patient for verification.
Ambulatory EHR systems: Report improper alternatives
Examine your electronic prescribing
systems to see if this problem exists.
Health systems may not have the
ability to disable automatic
“alternative” alerts. Thus, educate
providers to critically evaluate
suggested alternatives when
reviewing these alerts. We also
encourage you to contact your IT
vendor immediately about the
problem. Please notify ISMP of any
issues you may be having with this
feature or other issues that result in
the presentation of possible wrong
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 3
January – April 2014
ISMP
Problem
No.
alternative to clorazepate.
Incorrect alternatives may be
received by the IT vendor from
the pharmacy benefit manager or
a drug information vendor.
04/1
4
Angeliq is a hormone-based
medicine used to relieve the
symptoms of menopause. Errors
have occurred where it was
prescribed improperly as an oral
contraceptive. Women using
Angeliq instead of an oral
contraceptive could become
pregnant.
02/1
4
ISMP has received more reports
that manufacturers are using
identical or very similar product
codes—the middle 4 digits of the
NDC number—for different
products. While each 11-digit
NDC number is unique, the
product code is not required to be
unique amongst all products. A
recent report involved OXcarbazepine 600 mg (NDC 519910294-01) and oxaprozin 600 mg
(NDC 00093-0924-01).
04/1
4
A community pharmacy
technician interpreted a faxed
prescription for “MMF 1000 mg
BID” as metFORMIN, an
antidiabetic agent. However, the
prescription was actually for the
immunosuppressive agent
mycophenolate mofetil. The fact
that both drugs can be
prescribed in 1,000 mg doses to
be administered twice-a-day
increases the risk of error.
May 2014
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
information.
ANGELIQ (drospirenone and estradiol)—not a birth control pill!
Alert individuals who might prescribe
and receive oral contraceptives about
this risk. Store packages of Angeliq
separately from oral contraceptives in
prescribers’ offices, clinic settings, and
community pharmacies. Ideally,
consider a pop-up alert for prescriber
order entry systems.
Middle four strike again
Educate pharmacy personnel to use
the entire NDC number when
manually verifying product selection.
Compare the NDC number on the
manufacturer’s product label with the
NDC number printed on the
pharmacy-generated label. The
implementation of barcode scanning
during the production stage of the
dispensing process can identify when
the wrong product is selected from the
shelf.
Error-prone abbreviation of the month: MMF
Avoid the use of any drug name
abbreviation when communicating
prescription information.
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 4
January – April 2014
ISMP
May 2014
AmbulatoryCare ActionAgenda
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 5