April – June 2012
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 2012 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 description of the medication safety problem, 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’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). The Action Agenda is also available for download in a Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1203.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.
Many product-related problems can also be viewed in the ISMP Medication Safety Alert! section of our website at: www.ismp.org. Continuing education credit is available for nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
No.
Problem
(13)
A physician prescribed PN for a 16year-old boy (72 kg) using a standard
pediatric template that prom-pted
orders for most nutrients in per kg units
(e.g., mEq/kg). The pharmacy
template for patients more than 40 kg
required entry of nutrients in per day
units (e.g., mEq/day). The pharmacist
failed to change the prescribed per kg
doses to the per day doses. The
patient received an exceedingly hypotonic solution (138 mOsm/L) because
2,600 mL of sterile water for injection
was used erroneously.
(9),
(10)
A 2-year-old boy accidentally gained
access to a used fentaNYL patch
while visiting his great-grandmother
in a nursing home. The boy died and
the medical examiner found a
fentaNYL patch in the boy’s throat.
Investigators later found improperly
discarded used patches at the
nursing home.
July 12, 2012
—ISMP high-alert medication
Recommendation
Organization Assessment
Action Required/
Assignment
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors
Date Completed
Be sure the templates for prescribing
PN and entering orders into the
automated compounding device
software (or pharmacy computer)
match, both in chronological order
and measurement units. Use a total
daily dose when prescribing nutrients
for adults and daily weight-based
doses (mg/kg/day) when prescribing
nutrients for pediatric patients. Build
and heed automated warnings
regarding excessive nutrient doses.
Safe fentaNYL patch disposal
A National Alert Network (NAN)
warning was issued about proper
disposal of fentaNYL patches
(www.ismp.org/NAN/files/NAN20120425.pdf). Product labeling
states used patches should be
flushed down the toilet. Follow-up
with the FDA revealed that flushing
used patches is intended for
disposal in the home. In healthcare
organizations, patches may be
disposed of in a secure sharps
container, and witnessed and
documented according to policy.
ISMP MedicationSafetyAlert!

QAA 1
April – June 2012
ISMP
Problem
No.
(8)
The ON-Q pump, intended to infuse
anesthetic solution around surgical
wound sites, incorporates tubing that
attaches to infusion equipment with a
Luer connector, which is common to
IV lines. With bupivacaine and other
local anesthetic solutions, patient
harm is possible if the ON-Q pump is
inadvertently attached to an IV line.
(7)
As predicted by the
anesthesiologist in our Beyond
Blame film who was present 15
years ago when a young boy died
after receiving a local injection of
EPINEPHrine 1:1,000 instead of
lidocaine with EPINEPHrine
(1:100,000), mix-ups between
these products continue to
happen. It is hard to understand
why well-known errors like this
continue to happen when
prevention strategies have been
well publicized.
(12)
A technician accidentally sprayed
iron dextran injection on her
ChemoPlus Protective Gown
sleeve but it seeped through onto
her clothes. While the ChemoPlus
product description states that the
fabric is “splash resistant,” the
gowns do not meet OSHA, ASHP,
or ONS recommendations for
July 12, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
However, some states may have
other requirements, so check with
DEA and your pharmacy licensing
board.
ON-Q PainBuster Post-Op Pain Relief System (I-Flow Corporation) has a Luer connector
Affix a label to the ON-Q solution
container stating, “Warning: Regional
Block Only.” Always trace the
solution to the patient access point or
vice versa to prevent inadvertent
attachment of the ON-Q tubing to an
IV access port.
Concentrated EPINEPHrine mistaken as lidocaine with EPINEPHrine
Supply EPINEPHrine for topical
use in a pour-bottle with an
auxiliary label that states
“TOPICAL.” Or, replace the need
for vials of topical EPINEPHrine
with presoaked EPINEPHrine
pledgets prepared in advance of
procedures. Do not place
medication intended for injection
(e.g., local anesthetic) in an open
container (e.g., bowl).
Covidien ChemoPlus gown may not afford worker protection
Don’t be misled into believing you
are maximally protected during
preparation and administration of
chemotherapy and other
hazardous drugs by the brand
name “ChemoPlus.” If you are
using ChemoPlus gowns, be sure
they are poly-coated and meet
OSHA, ASHP, and ONS
ISMP MedicationSafetyAlert!

QAA 2
April – June 2012
ISMP
Problem
No.
chemotherapy protection. Only the
company’s ChemoPlus PolyCoated and the ChemoBloc PolyCoated Gowns meet the
recommendations and are
appropriate personal protective
equipment when handling
chemotherapy and other
hazardous drugs.
(8)
According to our recent survey,
drug shortages—particularly with
DOXOrubicin, fentaNYL,
morphine, electrolytes, antibiotics,
phentolamine, and
phytonadione—have extracted a
significant toll on patient safety
during the past year. The most
often cited problems involved
suboptimal treatment from use of
an alternative medication that was
not the drug of choice, errors with
alternative medications, and errors
when a pharmacy attempted to
compound a product or strength
no longer available.
(9)
Use of single-dose or single-use
vials for multiple patients can lead
to contamination and spread of
life-threatening infections and is,
thus, not recommended, as
reiterated by the Centers for
Disease Control and Prevention
July 12, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
recommendations.
Harm associated with drug shortages
When faced with a drug shortage,
conduct a mini failure modes and
effects analysis (sample format
at:
www.ismp.org/Newsletters/acute
care/articles/20101007.asp) to
assess the potential hazard to
patients and potential misuses of
alternative products. Determine
how to best manage the risk of
serious errors and adverse
reactions to alternative drugs, and
make any necessary procedural
and technological changes to
support safe use. When possible,
have pharmacy prepare and
dispense alternative drugs in the
most ready-to-use form.
Additional guidance during drug
shortages can be found at the
above link.
Proper use of single-dose vials
It is imperative that drug
shortages and drug waste
concerns are dealt with
appropriately and that single-dose
or single-use vials are used as
intended. However, the CDC
notes that shortages of some
ISMP MedicationSafetyAlert!

QAA 3
April – June 2012
ISMP
Problem
No.
(CDC) in response to concerns
that such a policy contributes to
drug shortages
(www.cdc.gov/injectionsafety/CDC
position-SingleUseVial.html).
(9)
A 20,000 units/mL heparin vial
was found in a hospital’s operating
room despite a decision to not
stock this unsafe concentration. It
was determined that an organ
harvesting team had left the
unused vial behind. In another
case, a hospital-contracted renal
transplant service left sodium
chloride 23.4% (used to reduce
cramping during hemodialysis) on
several nursing units. Staff
unaccustomed to the atypical
stock can mistake the products for
less concentrated forms of the
drugs.
(11)
With the Asept drainage system
for pleural effu-sions and
malignant ascites, a secure
connection is made between the
catheter and a vacuum bottle that
collects the drainage via a Luer
lock. It’s possible for the drainage
catheter’s female Luer connector
to be inadvertently connected to
the male end of IV tubing or a
syringe of medication instead of
the vacuum bottle tubing.
(11)
In May, CMS announced that
July 12, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
essential medications may
warrant pharmacy repackaging to
subdivide contents of unopened
single-dose/single-use vials via
implementation of meticulously
applied practice and quality
standards following USP Chapter
<797>.
High-alert medications left behind by contracted services
When outside groups contract to
provide services, hospital
leadership must work with the
pharmacy to ensure that the
medications and dosage forms
that might be used are reviewed
and agreed upon by the
pharmacy. At that time,
alternative products may be
discussed and/or arrangements
made to securely store products
normally unavailable at the
hospital. Pharmacy staff should
also conduct regular visits to
patient care units to observe drug
storage.
ASEPT Drainage System (B. Braun Interventional Systems) has Luer connector
The manufacturer is now printing
DRAIN ONLY on the valve and a
red end cap provided with the
tubing. Hospitals should also
label the end of the drainage
catheter, and roll up excess
tubing (including the female Luer
connector) and shield it under a
dressing when not in use. Trace
all line attachments from the
source to the patient or vice
versa.
Centers for Medicare & Medicaid Services (CMS) citing reuse of insulin pens
Educate practitioners who
ISMP MedicationSafetyAlert!

QAA 4
April – June 2012
ISMP
Problem
No.
hospitals will be cited if surveyors
identify sharing of insulin pens
(www.ismp.org/sc?id=77).
Regurgitation of blood into the
insulin cartridge after injection
risks disease transmission if the
pen is used for more than one
patient, even if the needle is
changed.
(8)
A clinician accidentally
programmed a pump to deliver
250 mL (2,500 mg) of IV
acetaminophen instead of 25 mL
(250 mg). The error was detected
when the nurse called the
pharmacy for additional 100 mL
vials to administer the dose.
Misprogramming the dose in mL
instead of mg has also been
reported in Europe, where the
drug has been on the market
longer than in the US.
(10)
Plavix was mistakenly dispensed
in response to an order for
Pradaxa. Plavix is available in 75
mg and 300 mg tablets (usual
dose 75 mg daily), and Pradaxa is
available in the US in 75 mg and
150 mg capsules.
(12)
Bullying, incivility, and other forms
of disrespectful behavior are
rampant in healthcare. Focusing
on disrespectful physician
behavior, Dr. Leape and
colleagues, who recently
published articles in Academic
Medicine, classify the behavior
July 12, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
administer medications via pens
about the risks associated with
sharing pens (CMS
announcement suggested that
some may not be aware of this
risk). Dispense pens for individual
patients, with a pharmacy label
that includes the patient’s name.
IV acetaminophen and overdoses in kids
Administer IV acetaminophen
using a smart infusion pump with
maximum dose settings identified
and active in the drug library.
Require pharmacy preparation of
IV acetaminophen doses that are
less than the 1 g strength of the
commercially available product.
Labeling notes the solution is
stable for 6 hours, but the company provided ISMP with written
attestation that the solution is
stable for at least 24 hours.
PRADAXA (dabigatran etexilate) and PLAVIX (clopidogrel) mix-up
Use signs or reminders on
shelves in storage areas to warn
staff of the look-alike drug name
risk to help prevent mix-ups.
Dr. Leape and colleagues call for a culture of respect
Responsibility for addressing
disrespectful behavior in the
clinical setting belongs to
organizational leaders, who need
to: raise awareness of the
problem; create a sense of
urgency to change; revise policies
that affect hours, workloads, and
ISMP MedicationSafetyAlert!

QAA 5
April – June 2012
ISMP
Problem
Recommendation
into six categories: disruptive
behavior; humiliating or
demeaning treatment; passiveaggressive behavior; passive
disrespect; dismissive treatment of
patients; and systemic disrespect.
The authors suggest that the
widespread disrespect that
persists in healthcare is a
substantial barrier to patient safety
progress.
mitigation of physical risks;
establish a code of conduct and
details for managing disruptive
behaviors; address systemic
issues such as environmental
stressors that cause disrespectful
behavior; and create a learning
environment where medical
students are mentored with
mutual respect.
No.
(12)
QuarterlyActionAgenda
A nurse gave a patient 5 drams
(18.45 mL, 1.845 g) of
acetaminophen concentrate liquid
(100 mg/mL) instead of 5 mL. The
dose was measured in a cup with
scales labeled in drams, fluid
ounces, cc, mL, tsp, and tbsp.
Confusion has been reported
frequently between drams,
ounces, mL, tsp, and tbsp.
July 12, 2012
Organization Assessment
Action Required/
Assignment
Date Completed
Apothecary measurement system a factor in medication errors
ISMP supports complete adoption
of the metric system for
prescribing and measuring liquid
doses. The hospital should use
oral syringes or dose cups without
apothecary gradations to
measure and administer oral
liquid medications.
ISMP MedicationSafetyAlert!

QAA 6