January – March 2012
ISMP
QuarterlyActionAgenda
Oneof the most important ways toprevent medication errors is to learn about problems that have occurred in other organizations and to use that information toprevent similar problems at your practice site. Topromote such aprocess,
thefollowing selected items fromtheJanuary-March 2012 issues of theISMP Medication Safety Alert! have been prepared for an interdisciplinary committee tostimulate discussion and action to reducethe risk of medication errors. Each item
includes a description of themedication safety problem, recommendations toreducethe risk of errors, and theissue number to locate additional information as desired. Look for our high-alert medication icon under the issuenumber if theagendaitem
involves oneor more medications on theISMP’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). TheAction Agenda is alsoavailablefor download in a Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1202.doc) that allows expansion of the columns in thetable designated 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 websiteat: www.ismp.org. Continuing education credit is available for nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
Problem
No.
(6)
Exparel, a local anesthetic
intended for infiltration into a
surgical wound to produce postop analgesia, looks a lot like
propofol, a drug used for
sedation. Both products are a
milky white emulsion used in the
operating room, so unlabeled
syringes could result in
misadministration, potentially
resulting in a fatality.
(4)
ISMP has received reports of
overdoses due to misprogramming
infusions with custom concentrations
that do not employ a hard minimum
concentration alert. Accidentally
programming a lower concentration
than the actual product concentration
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. Without a hard minimum
concentration limit, errors due to the
misprogramming of an infusion pump
can lead to life-threatening events.
April 5, 2012
Recommendation
—ISMP high-alert medication
Organization Assessment
Action Required/
Assignment
Inadvertent injection of EXPAREL (bupivacaine liposome suspension injection) intravenously
Date Completed
Separate the storage of these two
drugs. Require proper labeling of all
syringes that contain propofol or
Exparel, even if the medication will
be immediately used. Establish a
routine double check to make sure
any unused medication in a syringe
containing Exparel never leaves the
sterile field without a label. See
additional recommendations at:
www.ismp.org/NAN/ files/NAN20120318.pdf.
Smart pump custom concentrations without hard “low concentration” alerts
Assess vulnerability to this type of
error. Clarify with staff 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 drug infusions. If a
custom concentration is needed, set a
hard minimum concentration limit.
Use distinctive labels to distinguish
custom concentrations. Express the
drug concentration on the label and
MARs the same way it needs to be
entered into the pump (e.g., mg/mL,
total drug/total volume).
ISMP MedicationSafetyAlert!

QAA 1
January – March 2012
ISMP
Problem
No.
(1)
An order for “eribulin” (eribulin
mesylate, HALAVEN) was
misinterpreted by a pharmacist
and entered into the computer as
epirubicin. Both drugs are
associated with breast cancer
treatment, but typical dosing is
very different and should have
prompted a call to the prescriber
for verification.
(1)
QuarterWatch™ analysis of
adverse events reported to FDA
showed a large number (505) of
hemorrhagic events with
dabigatran, more than any other
drug including warfarin (176).
Events involved mostly elderly
patients. Patients with mild renal
failure had dabigatran blood
levels 50% higher than patients
with normal renal function,
although prescribing information
suggests dosage adjustment only
for severe renal impairment.
(1)
According to a recent study
(www.nejm.org/doi/
full/10.1056/NEJMsa1103053?qu
ery=featured_home), warfarin,
insulin, oral antiplatelet agents,
and oral hypoglycemics
accounted for more than twothirds of the drugs tied to
hospitalization for adverse drug
events in older adults. Most
events were associated with
unintentional overdoses.
April 5, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Chemotherapy mix-up between eribulin mesylate and epirubicin
Add the salt “mesylate” to the
eribulin listing in computer systems,
and apply tall man lettering
(eriBULin mesylate, EPIrubicin) to
prevent name mix-ups. A
pharmacist should verify and independently recalculate the dose of
any antineoplastic agent before
dispensing it. Any questions should
result in a direct query to the
prescriber.
Adverse events with dabigatran during quarter 1 of 2011
Alert prescribers to reports of
hemorrhagic events and dosing
issues associated with elderly
patients with renal impairment. The
drug’s manufacturer reported it is
working with FDA to provide better
guidance to physicians on treating
elderly patients, especially those
with transient (e.g., contrast media
use) or chronic impaired renal
function.
Medications associated with adverse events that led to hospitalization
Provide specific medication errorprevention education to hospitalized
patients who are discharged on
warfarin, insulin, oral antiplatelet
agents, and oral hypoglycemic
agents. Pay particular attention to
the prevention of dosing errors.
ISMP MedicationSafetyAlert!

QAA 2
January – March 2012
ISMP
Problem
No.
(4)
At least three fatalities have been
reported in Europe due to
inadvertent administration of IV
bortezomib into the intrathecal
space. These events involved
intrathecal chemotherapy
scheduled on the same day/time
as the IV bortezomib. Intrathecal
chemotherapy and IV bortezomib
are both administered in small
volumes via syringes, increasing
the likelihood of a mix-up.
(1)
Repeated events suggest
widespread misunderstanding
that sterility can be maintained
between patients by affixing a
fresh needle on a pen device.
Studies have shown that
biological contamination occurs in
up to half of all reused insulin
pens. This concern led the CDC
to issue a clinical reminder
(www.cdc.gov/injectionsafety/
clinical-reminders/insulinpens.html) regarding increasing
reports of improper use of insulin
pens.
(5)
Inadvertent tubing
misconnections are frequent and
preventable errors that pose a
significant risk to patient safety
and can result in devastating
outcomes. Because of human
factors, the clinical environment,
and the interconnectivity of Luer
connectors, healthcare
April 5, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Bortezomib deaths due to intrathecal misadministration
Administer intrathecal
chemotherapy at a different time
than IV chemotherapy. Verify that
intrathecal medication has been
administered before dispensing IV
bortezomib (or vice versa) for
patients receiving medications via
both routes. Label bortezomib
syringes with warnings about IV use
only. Require a time-out procedure
and an independent check before
administering intrathecal medication
or chemotherapy.
Do not use an insulin pen for multiple patients
To reduce the risk of cross
contamination, insulin pens should
be assigned to individual patients
and labeled using a “flag” attached
to the body of the pen without
covering the drug name. If ongoing
education and monitoring of proper
use of pen devices cannot be
accomplished, hazardous
conditions may persist, and
hospitals may need to consider
whether patients would be safer by
dispensing vials or prefilled syringes
of insulin.
Tubing Misconnections Self Assessment for Healthcare Facilities
Hospitals are encouraged to
complete a new self assessment
tool (www.baxter.com/healthcare_
professionals/clinical_center_of_exc
ellence/connections_portfolio/progr
ams/tubing_misconnection_index.ht
ml) that guides users to evaluate
current delivery systems and mating
devices. By completing the
ISMP MedicationSafetyAlert!

QAA 3
January – March 2012
ISMP
Problem
No.
professionals have mistakenly
connected the wrong devices and
delivered substances via the
wrong route.
(2)
The use of multidose vials in the
operating room (OR) has resulted
in infection outbreaks and errors.
Cross contamination is always a
possibility when using multidose
vials. Also, when medications are
supplied in quantities that exceed
the amount typically given,
practitioners may misinterpret the
amount in the vial as a single
dose, leading to overdoses.
(3)
ISMP continues to identify
instances in hospitals where
resuscitation carts have outdated
versions of the Broselow tape,
which is used to identify doses of
medications for children based
on body length.
(4)
Studies show that Cosmegen
diluted at concentrations of 10
mcg/mL or higher in sterile water,
normal saline, and 5% dextrose
are stable for 10 hours (room
temperature). But dilution with
April 5, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
assessment, hospitals will identify
potential tubing misconnection risks
and develop an action plan to
mitigate risks through processes,
device selection, and education.
Avoid multidose vials in the operating room
The Association of periOperative
Registered Nurses (AORN) recently
released a set of recommended
practices (http://alturl.com/xapaa)
that include a recommendation to
collaborate with pharmacists to
procure and store only single-dose
vials in the OR and post-anesthesia
unit. Multi-dose vials should be
avoided. The document outlines
other best practices in the OR when
procuring, prescribing, dispensing,
administering, and monitoring the
effects of medications.
New Broselow tape available
Ensure that the newly available,
most up-to-date Broselow tape
(dated 2011 Edition A) is available
on resuscitation carts as
appropriate (www.arm
strongmedical.com/index.cfm/go/pr
oduct.detail/sec/3/ssec/14/fam/2371
). The tape has revised zones
based on new national data on
length-weight relationships in
children, making these tapes more
accurate.
Do not infuse COSMEGEN (DACTINomycin) in sterile water
Dilute Cosmegen only in 5%
dextrose or normal saline during
preparation for IV administration.
ISMP MedicationSafetyAlert!

QAA 4
January – March 2012
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
sterile water could result in a
hypotonic solution that would
cause hemolysis if administered
IV.
(3)
An order for Rapaflo 8 mg daily
was transcribed incorrectly as
Rapamune. Due to a bug in a
software upgrade (since
corrected), some of the
medications in the database
would not appear on the screen if
the full drug name was entered.
This reinforced an at-risk
behavior of only typing in the first
few characters of a drug name,
which in this case (R-A-P) called
up the wrong drug.
(5)
FDA discovered an unlicensed
supplier selling fake
bevacizumab injectables (under
the brand name AVASTIN) to
oncology practices. The fake
product contained no active
ingredient.
(6)
Vials of calcium gluconate and
cupric sulfate were mixed up
when preparing infusions. Both
vials are similar in size and have
a similar pink color on the label,
although one is from American
Regent (cupric sulfate) and the
April 5, 2012
Mix-ups between RAPAFLO (silodosin) and RAPAMUNE (sirolimus)
Hospitals should add this drug
name pair to their list of look-alike
drug names. Prescribers can help
prevent mix-ups by including the
drug’s purpose when ordering
medications and regularly reviewing
the patient’s medication list. The full
drug name should be used
whenever feasible instead of the
first few characters when entering
orders into the pharmacy computer.
Prevent counterfeit drugs from reaching patients
All healthcare professionals, not just
pharmacists, need to be aware of
proper procedures for safely
procuring medications for patients.
The Partnership for Safe Medicines
provides resources for pharmacists,
nurses, and physicians to help
prevent counterfeit medicines from
reaching patients (http://safedr.ug/
for_pharmacists,
http://safedr.ug/for_nurses,
http://safedr.ug/for_physicians).
Look-alike vials of calcium gluconate (100 mg/mL) and cupric sulfate (4 mg/10 mL)
Separate storage of these products
in the pharmacy. If possible,
purchase one of the products from
a different manufacturer.
ISMP MedicationSafetyAlert!

QAA 5
January – March 2012
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
other from APP (calcium
gluconate).
(6)
Sharing eye drop containers
between patients and between
both eyes of one patient has led
to serious eye infections due to
cross contamination. While most
products include preservatives to
prevent growth of bacteria and
fungi, organisms can still thrive
on the tip of the bottle. Rates of
contamination as high as 35%
have been noted in some
studies; although infections are
rare, they can happen and even
cause blindness in some cases.
April 5, 2012
Eye drop-related infections
To reduce costs, ophthalmicspecialty hospitals often have
mandatory training, competency,
and monitoring programs to teach
and validate safe eye drop
administration. Hospitals without
this level of training and monitoring
should dispense separate
containers of eye drops for each
patient and each eye. Once
discharged, patients can use a
device (e.g., Owen Mumford) that
does not allow the bottle to touch
the eye when squeezing out the
drops.
ISMP MedicationSafetyAlert!

QAA 6