April – June 2015
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 2015 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 one or more medications on the ISMP List of High-Alert Medications (www.ismp.org/sc?id=479). The Action Agenda is also available for download in a Microsoft Word format
(www.ismp.org/newsletters/acutecare/articles/ActionAgenda1503.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.
Continuing education credit is available for nurses at: www.ismp.org/sc?id=480.
Key:
Problem
No.
(8)
Multiple life-threatening flecainide overdoses
in children have been reported. Math errors
have led to some errors when compounding
available tablets into a suspension for small
children. Preparing flecainide syringes in a
volume intended for another compounded
medication being prepared at the same time
has also been reported. Mistakes with
dosing information have occurred (e.g., mL
instead of mg), and caregivers have mixed
up the mL and teaspoon scales on a syringe
and administered 1 teaspoon instead of 1
mL. All the children recovered.
(10)
A child with congenital long QT syndrome
(LQTS) died after a physician prescribed
azithromycin, which he did not know prolongs
the QT interval and increases the risk of
torsades. The child developed complete
atrioventricular (AV) block, torsades, and
ventricular fibrillation. Resuscitation efforts
were unsuccessful. The electronic health
system did not warn the prescriber about the
drug-disease interaction because the alert
system was disabled. Even if the alert system
had been enabled, it would have only alerted
for the most severe interactions, and the drug
information system did not classify this
July 16, 2015
—ISMP high-alert medication
Organization
Assessment
Life-threatening errors with flecainide suspension in infants and children
Recommendation
Action Required/
Assignment
Date
Completed
Prescribe and express flecainide doses in
mg. In hospitals, pharmacy labels should
specify the dose in mg and mL followed by
the concentration, and all doses should be
dispensed in oral syringes. In retail
pharmacies, embed a flow restrictor in the
bottle neck and provide an oral syringe.
Remind parents to secure the child-resistant
cap after use. On the label, state the dose in
mL, and the concentration next to the drug
name below the directions. Treat overdoses
with sodium bicarbonate or sodium chloride
boluses and circulatory support.
The absence of a drug-disease interaction alert leads to a child’s death
Test your order entry system to determine if
an alert will appear when a drug that
prolongs the QT interval and increases the
risk of torsades is entered for a patient with
a history of prolonged QT interval or
torsades. CredibleMeds (www.cred
iblemeds.org) is a resource that continually
updates a list of drugs that prolong the QT
interval. Build or modify the severity of alerts
to warn about potential problems with these
medications. Document all comorbid
conditions in a structured diagnosis/problem
list field in the patient’s electronic record,
and link this to the prescriber and pharmacy
ISMP MedicationSafetyAlert!

QAA 1
April – June 2015
ISMP
Problem
No.
interaction at the highest severity level. The
patient’s congenital LQTS also was not
documented in the record to cause an alert.
(10)
(7)
(8,
11)
Patients on suicide precautions may remove
opioid transdermal medication patches or
obtain them from disposal bins and ingest
large doses of the medication by chewing
the patches.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
order entry systems to promote drugdisease interaction screening.
Opioid patches and suicide risk
Be sure suicide precautions include an
assessment to determine if the patient is
wearing a transdermal patch, and weigh the
risks and benefits of their use in this
population. Ensure secure patch disposal.
HYDROmorphone patient-controlled analgesia (PCA) basal infusion overdose
A telephone order for HYDROmorphone
A smart pump with a dose error-reduction
PCA included a basal infusion of 1.5 mg per system (DERS) could have alerted the nurse
hour. The correct basal dose was initially
to the error. A 15 mg/hour basal dose of
programmed and delivered using the original HYDROmorphone should result in a hard
order. But the order was transcribed onto
stop without the ability to override the
the medication administration record (MAR)
warning. An independent double check of
incorrectly as a basal rate of 15 mg per hour. the PCA settings also may have caught the
When a new pump was needed, the MAR
error. Only allow basal PCA doses for
was referenced, and the wrong basal
opioid-tolerant patients, and require
infusion rate was programmed. The patient
continuous electronic monitoring of the
was found unresponsive, treated with
patient’s respiratory status. Use of a
naloxone, and transferred to a critical care
preprinted order set may help guide an
unit.
appropriate dosing regimen for PCA.
A patient with hemodynamic
decompensation received desmopressin
instead of vasopressin. VASOSTRICT, a
new brand of vasopressin required
refrigeration, so the drug was no longer on
the crash cart. The medications were both in
the automated dispensing cabinet (ADC)
refrigerator on separate shelves labeled with
their generic names. The nurse mistakenly
grabbed desmopressin, which has less
vasopressor activity than vasopressin.
July 16, 2015
Desmopressin confused with vasopressin
Par Pharmaceuticals recently received FDA
approval to extend labeled stability of
Vasostrict to 1 year after removal from the
refrigerator. The drug can now be stocked
on crash carts. If both Vasostrict and
desmopressin are stocked in the
refrigerator, separate the medications and
clearly label their locations using the
Vasostrict brand name and the generic
names.
ISMP MedicationSafetyAlert!

QAA 2
April – June 2015
ISMP
No.
Problem
(12)
Three fluorouracil overdoses in ambulatory
settings were reported. One involved a
CADD ambulatory infusion pump that was
misprogrammed to deliver the full 2-day
course over 2 hours. Another error involved
a mix-up between an EASYPUMP
elastomeric infusion pump that infuses 2 mL
per hour with one that infuses 250 mL per
hour, causing the patient to receive the
entire 4-day course over less than 1 hour.
The third error led to a 5-fold overdose due
to a pharmacy miscalculation when
preparing the infusion.
(9,
12)
(9)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Accidental overdoses involving fluorouracil infusions
Administer fluorouracil infusions using
ambulatory smart pumps with dose errorreduction systems and other safeguards.
Develop a structured process for conducting
independent double checks prior to
administration. Ensure that the information
needed to program infusion pumps is
prominently displayed in a standard way on
pharmacy labels. Improve rapid recognition
of toxicity and define treatment protocols for
overdoses. Order single daily doses of
fluorouracil and avoid contraindicated
medications. Ensure staff receive an
appropriate level of training and maintain
competency.
Look-alike products: Calcium gluconate, sterile water, and 0.9% sodium chloride
Now that calcium gluconate 1 g/10 mL from
You can purchase 20 mL vials of sterile water
Fresenius Kabi is available in plastic vials, it
to help differentiate the products based on
looks very similar to 10 mL sterile water for
vial size. But staff who are accustomed to
injection vials from Hospira. The vials are
sterile water in 10 mL vials may still pick up a
similar in size and cap color. The calcium
10 mL vial of calcium gluconate by accident.
gluconate vials also look like Fresenius Kabi
Since purchasing from different
vials of 0.9% sodium chloride injection,
manufacturers is not always feasible in light
although the sodium chloride vials have a
of ongoing shortages, we encourage barcode
pink, not purple, cap. A mix-up in the
scanning, increasing awareness of the risk,
pharmacy or on the nursing unit could lead to and storing these products far apart to help
an adverse outcome.
prevent errors.
Risk of overdose with transdermal patient-controlled iontophoretic fentaNYL (IONSYS)
Ionsys, a new transdermal iontophoretic
Ionsys may have a place in patient care
fentaNYL system, allows patients to activate given that this form of patient-controlled
July 16, 2015
ISMP MedicationSafetyAlert!

QAA 3
April – June 2015
ISMP
Problem
No.
40 mcg doses up to 6 times an hour by
pushing a button twice on the credit cardsize device that adheres to the skin. Up to
240 mcg per hour can be administered, and
drug delivery can be activated up to 80
times per 24 hours. So, excessive button
pushes can lead to serious injury.
(10)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
analgesia (PCA) does not require a PCA
pump. Assess whether or not patients are
appropriate for this product. Patient
monitoring, including pulse oximetry and
capnography, will be needed to detect
excessive dosing and unexpected opioidinduced respiratory depression.
Mix-ups between dropperful and drop of vitamin D doses lead to overdoses
An infant with dystonia and cachexia was
Practitioners caring for babies should never
hospitalized with very high calcium blood
assume that parents know which vitamin D
levels. The mother had been administering a
product to purchase, how many units to
dropperful per day of Vitamin D3 Drops for
give, or how it should be administered. For
Kids (Natural Factors, Canada) rather than a
infants, errors are less likely with a vitamin D
drop (400 units). Confusion between drops
product that contains 400 units per mL, not
and dropperful has led to previous overdoses. 400 units per drop.
(9)
A hospital reported diversion in the pharmacy
involving morphine ADD-Vantage vials.
Evidence of tampering was found with 47 of
the 100 mg vials and 12 of the 250 mg vials.
Staff found it was easy to remove the plastic
sleeve from over the vials without tearing the
manufacturer’s label, which does not adhere
to the sleeve. Once the sleeve is off, the
rubber stopper can be removed and the
morphine can be withdrawn and replaced
with saline.
(12)
A prescription for warfarin 1 mg with
directions to take 3 tablets daily (3 mg) was
sent electronically to a pharmacy upon a
patient’s discharge. Later, when the
prescriber learned that a 3 mg tablet was
Drug diversion with morphine (25 mg/mL) ADD-Vantage containers
Establish a surveillance program to detect
potential drug diversion, and put together an
internal group that can be quickly engaged
to investigate any concerns. The team
should always include the patient/medication
safety officer, pharmacy director or
manager, nurse executive, medical staff
leader, risk manager, and security manager
(unless one of these leaders is involved in
the suspected diversion).
Lack of e-prescribing interoperability leads to double warfarin dosing
July 16, 2015
Inform providers that cancellation of eprescriptions is not communicated to all retail
pharmacies electronically, so they must call
the pharmacy. Provide discharge education
using the “teach back” method to ensure
ISMP MedicationSafetyAlert!

QAA 4
April – June 2015
ISMP
(11)
(11)
Organization
Assessment
Problem
Recommendation
available, he electronically cancelled the first
prescription and sent a new one for the 3 mg
tablet daily. The pharmacy never received
notification that the first prescription was
cancelled. Both prescriptions were filled, and
the patient took one 3 mg tablet and three 1
mg tablets daily for days before visiting the
anticoagulation clinic with an elevated INR.
patients understand their warfarin doses.
Consider giving patients discharged on
warfarin a free educational leaflet on warfarin
available from ISMP (www.ismp.org/ahrq/).
No.
(12)
QuarterlyActionAgenda
Action Required/
Assignment
Date
Completed
Confusion between SEASONALE (ethinyl estradiol and levonorgestrel) and seasonal allergies
Inaccurate allergies may be documented
If you list Seasonale in your allergy
when patients report “seasonal allergies” but database, remind staff about potential mixstaff accidentally select Seasonale, the
ups with seasonal allergies, and to never
contraceptive, in the allergy field because
select this drug unless the patient is truly
“seasonal” allergies may not be a choice to
allergic to the medication.
select. This could lead to inappropriate
discontinuation of birth control or hormone
replacement therapy.
The numbering system that an electronic
health record and e-prescribing system
vendor had programmed into an insulin
“protocol” led to dosing errors when nurses
confused the number of units with the order
numbering system used in the protocol table.
In another case, a numbered order for 2
million units of penicillin G was preceded by
the number 1 and was misinterpreted as 1.2
million units.
Numbering insulin orders led to dose confusion and errors
Numbering orders adds to the potential for a
medication error. Work with your vendor to
remove numbers that may interfere with
order clarity. Also avoid listing a numerical
dose before the drug name to reduce the
risk of confusion.
Alteplase (ACTIVASE) and tenecteplase (TNKase) confusion in the emergency department (ED)
ISMP highly recommends not using any
A patient with stroke symptoms was
inadvertently given tenecteplase instead of
drug name abbreviations—including tPA or
alteplase in the ED. The drug was referred
TNK.
to as “tPA.” At an automated dispensing
cabinet (ADC), a nurse typed “t” and
tenecteplase appeared on the screen, which
she selected, removed, and administered.
This has been a recurring error.
July 16, 2015
ISMP MedicationSafetyAlert!

QAA 5
April – June 2015
ISMP
No.
July 16, 2015
Problem
QuarterlyActionAgenda
Organization
Assessment
Recommendation
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 6