July – September 2008 ISMP QuarterlyActionAgenda 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 items fromthe July-September 2008 ISMPMedication Safety Alert! havebeen prepared for an interdisciplinary committee tostimulatediscussion and action toreducetherisk of medication errors. Each item includes adescription of themedication safety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional information as desired. Theitems with thehighest priority appear at thebeginning half of theagenda. Many product-related problems can alsobevisualized in theISMPMedication Safety Alert! section of our websiteat www.ismp.org. TheAction Agendais alsoavailablefor download in aWord format (www.ismp.org/Newsletters/acutecare/articles/ActionAgenda0804.doc) that allows expansion of thecolumns in thetabledesignated for organizational documentation of an assessment, actions required, and assignments for each agendaitem. Continuing education credit is availablefor nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp. . Key: No. Problem (13 ) Epidural infusions with bupivacaine have been accidentally administered IV— particularly to women in labor—resulting in fatalities. A Black Box warning for bupivacaine notes the drug can cause profound disturbances in cardiac rhythm and contractility that are resistant to typical resuscitation efforts. (16 ) A young man with lymphoma died after accidental intrathecal administration of IV vindesine, an investigational chemotherapy agent. Any of the vinca alkaloids (vinBLAStine, vindesine, vinorelbine, and vinCRIStine) can cause fatal neurological April 19, 2007 —ISMP high-alert medication Recommendation Organization Action Required/ Assessment Assignment Epidural bupivacaine given IV leads to fatalities Date Completed Consider use of other epidural agents that may be less toxic than bupivacaine. Ensure delivery of the correct epidural medication to the correct unit, immediately before use if possible. Affix colorful labels to bags and syringes that contain epidural medications stating “For epidural use only.” A checklist of recommendations appear at: www.ismp.org/ Newsletters/acutecare/articl es/20080703.asp. Intrathecal administration of IV vindesine causes fatality Vinca alkaloids should never be in the same treatment room as intrathecal medications. Also, dilution of vinca alkaloids in an infusion bag is highly recommended to reduce the risk of confusion with intrathecal medication in syringes. Dilution also provides a volume too large for intrathecal ISMP MedicationSafetyAlert! QAA 1 July – September 2008 ISMP Problem No. effects if given intrathecally instead of IV. (17 ) (14 ) ISMP has received reports of overdoses with patient controlled analgesia (PCA) due to misprogramming the concentration of the narcotic. Accidentally programming a lower concentration than actually in the pump, results in the delivery of a higher dose than prescribed since more volume will be infused. The resulting “low concentration” alert from smart pumps has been misinterpreted as a “low dose” alert, which is more common when titrating drugs before discontinuation. As many as 17 infants received 100 times more heparin than intended after incorrect preparation in the pharmacy. Other recent neonatal heparin dosing errors have been caused by the presence of unfamiliar heparin strengths in the hospital due to the heparin recall; failed October 23, 2008 QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed administration. Misprogramming PCA concentration leads to dosing errors Assess vulnerability to this type of error. Clarify any confusion regarding the inverse relationship between dose and concentration, and the differences between “low concentration” and “low dose” alerts. Limit the number of standard concentrations for PCA drugs. If custom concentrations are needed, use distinctive labels to distinguish it from a standard concentration. Express the concentration of the drug in the same manner it needs to be entered into the pump (mg/mL or total drug/total volume) on the label and medication administration records. Heparin errors continue despite prior, high-profile, fatal events Employ validation processes when preparing neonatal heparin products, such as barcode technology, refractometry readings (which should be as low as the diluent alone since the heparin concentration used for neonates is low), or manual double checks. Outsourcing the preparation of neonatal heparin flush syringes is another option. ISMP MedicationSafetyAlert! QAA 2 July – September 2008 ISMP Problem No. (13 ) (15 ) verification processes during preparation or administration; and variability in the strength of heparin used to maintain line patency Look-alike bag A pharmacy-prepared admixture of diltiazem labeled as Zosyn was almost administered to a patient, risking serious harm. The diltiazem had been prepared for another patient and returned to the pharmacy long after the patient’s discharge, along with another patient’s similar-looking bag of Zosyn. The diltiazem bag was accidentally returned to the Zosyn bin in the pharmacy. Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish, resulting in fewer errors among products with look-alike names. In a survey of readers, two-thirds (64%) reported that tall man lettering has actually October 23, 2008 QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed Use preservative-free prefilled heparin flush syringes when available. of diltiazem placed in ZOSYN (piperacillin and tazobactam) stock upon return to pharmacy Evaluate the process for returning discontinued drugs to the pharmacy and replacing them in stock to ensure timeliness and accuracy. The safest strategy is to use barcode technology when returning medications to stock, and to return medications to the pharmacy promptly after patients have been discharged. Use of tall man letters is gaining wide acceptance Tall man letters should be used to differentiate a standard set of look-alike drug name pairs on pharmacygenerated labels, drug selection screens, shelf labels, medication administration records, and order sets. To promote standardization, ISMP suggests following the tall man lettering scheme provided by FDA and ISMP for ISMP MedicationSafetyAlert! QAA 3 July – September 2008 ISMP Problem No. (15 ) (16 ) QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed prevented them from the standard drug name pairs dispensing or (www.ismp.org/Tools/tallmanl administering the wrong etters.pdf). medication. Medication reconciliation and patient education needed to lessen fatal medication errors in the home A review of US deaths Consumers need to be aware between January 1983 of the potential for harm and December 2004 with prescription and OTC showed a 360.5% drugs, especially when increase in fatal combined with alcohol and/or medication error (FME) street drugs. Medication rates in the home. FMEs reconciliation upon hospital in the home where admission and discharge, and alcohol and/or street education of patients about drugs were involved their home medications increased by 3,196%, before discharge can play a while those not role in lowering these associated with alcohol staggering statistics. increased by 564%. Proper positioning of pharmacy label on Hospira pumps will avoid interference with scanning The Hospira LifeCare PCA Companies such as Ameridose pump has a barcode and PharMEDium provide scanner to identify outsourced pharmacy prefilled drug vials compounding of fentaNYL and loaded in the pump. HYDROmorphone with labels FentaNYL and that can be read by Hospira HYDROmorphone are not PCA pumps. When a pump available in prefilled malfunctions or difficulty vials, so pharmacies is encountered setting up must pre-pare these the pump, staff should be drugs in empty glass educated to first clamp the vials with a pre-printed tubing to prevent accidental barcode that the pump administration during recognizes, enabling it manipulation of the pump. to start. If not placed Hospira offers instructions properly, the pharmacyon how to produce and apply applied label can pharmacy labels correctly so prevent the pump from the barcode can be read by reading the barcode and the pump. starting the pump. One October 23, 2008 ISMP MedicationSafetyAlert! QAA 4 July – September 2008 ISMP Problem No. QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed patient received an overdose of fentaNYL while a nurse was trying to manipulate the vial to start the pump. (13 ) (16 ) (16 ) SHRINKSAFE ID Bands make vials look similar A vial of Use ShrinkSafe selectively succinylcholine was and minimize the variety of found in a bin of neuromuscular blocking vecuronium. Both agents stored in clinical products were enclosed areas. in ShrinkSafe ID Bands. The Bands help identify paralyzing agents but make the vials look similar. Mix-ups can affect hemodynamic response given differences in the drugs. JANTOVEN (warfarin), JANUVIA (sitaGLIPtin), and JANUMET (sitaGLIPtin and metFORMIN) Jantoven, Januvia, and Confirming the diagnosis for Janumet have been patients taking any diabetes confused with each drug or warfarin can help to other. SitaGLIPtin is reduce errors if available in 25, 50, prescriptions for these and 100 mg strengths, medications are initially which is outside misread. For further warfarin’s dosage recommendations for range. But errors are preventing name mix-ups, possible if a decimal see: point is overlooked www.ismp.org/Newsletters/acu when prescribing te care/articles/20070809.as Jantoven 2.5 mg, or if p using a trailing zero when prescribing 5.0 or 10.0 mg. EPINEPHrine and ePHEDrine mix-ups A nurse misheard a Use prefilled EPINEPHrine telephone order for syringes and keep large October 23, 2008 ISMP MedicationSafetyAlert! QAA 5 July – September 2008 ISMP Problem No. ePHEDrine as EPINEPHrine. In addition to name similarities, the drugs have also been confused during selection of the product. Each drug is used as a vasopressor and vasoconstrictor, so storage is often near one another in the same clinical environment. Both products also may be packaged alike in 1 mL ampuls or vials. (19 ) (17 ) QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed vials of the drug out of clinical areas to reduce the risk of preparing large amounts. To prevent mishearing drug names, require “read back” of oral orders. Have pharmacy prepare all infusions and bolus doses except in emergencies. Use tall man lettering on computer inventory listings, shelf labels, and other places where the drug names are expressed. Caution when changing infusion duration on some infusion pumps Smart pump drug libraries should be programmed with the most common standard times for infusing medications (e.g., 30 minutes, 1 hour). Staff should be warned about the potential for this error, and each entry on the pump confirmation screen should be rechecked before starting the infusion. With some smart pumps, once the medication and dose per hour have been programmed, the infusion rate, volume to be infused (VTBI), and time are automatically calculated and appear in the correct fields. But if the nurse changes the infusion time—from 1 hour to 30 minutes, for example— the VTBI changes rather than the rate of infusion, risking partial administration of medication. CATHFLO ACTIVASE (alteplase; available in 2 mg lyophilized powder vials) and ACTIVASE (alteplase) During a code in the Complete orders (i.e., dose, cardiac catheterization route, administration lab, a pharmacist directions, in this case) called the pharmacy and should always be October 23, 2008 ISMP MedicationSafetyAlert! QAA 6 July – September 2008 ISMP Problem No. (18 ) (18 ) QuarterlyActionAgenda Recommendation Organization Assessment Action Required/ Assignment Date Completed asked for “t-PA.” The communicated, and pharmacy pharmacy staff thought should not dispense the drug was needed to medications without full help restore central prescribing information. In venous catheter non-urgent cases, using function and dispensed disease-specific protocols a 2 mg/2 mL syringe of and order forms would reduce Cathflo Activase the possibility of errors. instead of the intended 100 mg dose of Activase. Sodium phosphates overdose after recent process changes and implementation of smart pumps A technician mixed a Before making substantial dose of sodium changes, conduct pilot phosphates using an old testing, simulations, and a procedure, forgetting failure mode and effects that the hospital had analysis to identify switched to standard potential ways newly concentrations for designed processes may fail infusions since so they can be mitigated. eliminating the rule of Ensure communication about six and implementing the change to appropriate smart pumps. The staff and that the culture admixture contained 501 allows reporting of concerns mmol instead of 25 with new processes. Promote mmol. The error was not compliance with independent detected and the child double-check systems when died. Inadequate admixtures are prepared. preparation for the switch to smart pumps played a part in the error. Mix-up between lactated Ringer’s and oxytocin A woman in labor IV bags of oxytocin should received an unspecified be prepared in the pharmacy amount of IV oxytocin and boldly labeled to when her nurse thought differentiate it from an infusion bag lactated Ringer’s. Create contained lactated designated areas to place Ringer’s, resulting in medications needed during October 23, 2008 ISMP MedicationSafetyAlert! QAA 7 July – September 2008 ISMP QuarterlyActionAgenda Problem Recommendation emergency delivery of the baby. Distracted by the activity in the room, the nurse had failed to properly identify the infusion bag before hanging it. different phases of the labor and birth process (e.g., boldly labeled containers where the products can be placed in an organized manner). Use of point-of-care barcode technology can also help ensure that the right product has been selected for administration. No. October 23, 2008 Organization Assessment ISMP MedicationSafetyAlert! Action Required/ Assignment Date Completed QAA 8