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