July - September 2013
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 July-September 2013 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 ISMP’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). The Action Agenda is also available for download in a Microsoft Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1304.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
(16)
A 15-month-old child who had been sleeping
with his mother gained access to her fentaNYL
patch, ingested it, and was found
unresponsive when his mother awoke. He
later died. Similar events prior to this have
been just as tragic, yet little has been done to
assure patient education about proper use and
storage of fentaNYL patches. Until every
healthcare professional and health system
accepts personal responsibility for promoting
safe use of this drug, we are exposing one of
the most troubling examples of bystander
apathy in healthcare: a belief that we don’t
need to intervene because others will.
(18)
—ISMP high-alert medication
Organization
Assessment
FentaNYL patch fatalities linked to “bystander apathy”
Recommendation
Action Required/
Assignment
Date
Completed
No patient should walk out of a doctor’s
office, hospital, clinic, or pharmacy without
face-to-face instructions on the use of
fentaNYL patches and related safety
concerns. All health professionals must
individually instruct patients and caregivers
and not rely on others to do it. ISMP has
developed a FREE patient education
checklist and consumer leaflet for use during
consumer education that can then be given to
the patient for reference (download the
checklist/leaflet at:
www.ismp.org/AHRQ/default.asp [must
register for initial access]).
Death and neurological devastation when IV vinca alkaloids are given intrathecally
Results from the ISMP International
Dispense IV vinca alkaloids in a minibag of
Medication Safety Self Assessment for
a compatible solution and never dispense
Oncology revealed that only 54% of US
and/or administer these drugs using a
hospitals dispense vinCRIStine in a minibag
syringe. Prohibit IV vinca alkaloids in areas
of compatible solution to prevent accidental
where intrathecal medications are
intrathecal administration. To date, there are
administered and/or stored. Confirm that
120 published cases of administration of
any prescribed intrathecal medications
vinCRIStine by the intrathecal route when the
have been administered before dispensing
drug was dispensed in a syringe, and zero
IV vinca alkaloids. For more
cases when dispensed in a minibag. Most
recommendations, visit: www.ismp.org/
events were related to mistaking IV
newsletters/acutecare/showarticle.asp?id=
vinCRIStine for an intrathecal medication
58.
(e.g., methotrexate, cytarabine).
October 3, 2013
ISMP MedicationSafetyAlert!

QAA 1
July - September 2013
ISMP
Problem
No.
(14)
(19)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
Stock ketamine in a lower concentration (10 mg/mL) in the emergency department (ED)
A pediatric patient received a 10-fold
In the ED, ketamine is often administered IV,
overdose of ketamine in the ED. A small
so a lower concentration (10 mg/mL) should
volume (0.175 mL) of ketamine (100 mg/mL)
be stocked. Concentrated ketamine products,
was needed for the child’s dose. The nurse
which result in lower dosing volumes, may be
doubted that such a small volume was
more appropriate for IM or intranasal (offneeded and drew up 1.75 mL, which he
label) use since larger doses are needed with
considered to be a more “normal volume.”
these routes.
Automated maximum dose alerts with hard stops for amphotericin B, methotrexate, and fentaNYL
ISMP has often written about mix-ups
Design hard stops in order entry
between conventional and lipid-based
computers for doses of conventional
amphotericin B, accidental daily dosing of oral amphotericin B greater than 1.5 mg per kg
methotrexate, and dosing errors with IV
or catastrophic limits, and for daily dosing
fentaNYL. Recent errors with these drugs led of oral methotrexate without a stop date
to the death of a patient who received
after 5 days or less. Program hard stops in
conventional amphotericin B in a dose for the smart infusion pumps to detect pump
lipid-based product, and serious injuries to
programming errors that would lead to
two toddlers—one of whom received
catastrophic doses with fentaNYL. The
methotrexate daily for 7 days and the other
intent is to halt the process or allow for a
an IV fentaNYL overdose after a pump
brief period of investigation to ensure
misprogramming error.
safety.
(16)
Experts agree that hepatitis B can be
eliminated in the US with proper vaccination.
Yet, one in three newborns leaves the hospital
without receiving this vaccination, and 800
become infected with hepa-titis B each year
because of perinatal exposure.
Help end hepatitis B by vaccinating newborns
Ensure that hepatitis B vaccine birth doses
are included in standard order sets,
universally administered before hospital
discharge, and that proper follow-up
occurs with a total of 3 or 4 doses at
properly spaced intervals.
(14)
A pharmacy technician mixed 0.27 mL of a
diluent with 5.13 mL of magnesium sulfate,
mixing up the volumes required (0.27 mL
magnesium, 5.13 mL diluent). The syringe
Syringe pull-back method of verifying IV admixtures unreliable
ISMP’s compounding safety guidelines
strongly dis-courage the syringe pull-back
method of verifying the contents of admixtures,
particularly for compounded sterile products
October 3, 2013
ISMP MedicationSafetyAlert!

QAA 2
July - September 2013
ISMP
Problem
No.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
pull-back method was used for checking
the admixture, so the error went unnoticed
because it was not clear which syringe was
associated with which vial. The syringe
pull-back method for checking admixtures
is unreliable.
(17)
with high-alert drugs
(www.ismp.org/sc?id=251). The contents of
these solutions should be verified immediately
before adding them to the diluent, and
syringes should be labeled if verification is not
completed shortly after drawing the solution
into the syringe.
Developing productive partnerships with technology and device vendors to improve staff training
Staff training is critical to optimize the use of
Work collaboratively with technology vendors
new technology, employ all its safety features, to deliver initial staff training and periodic
and prevent misuse that might lead to errors.
follow-up training. Make sure your purchasing
But users rarely read the vendors’ directions
agreement clearly details the training to be
for use, and organizations may not have the
provided. Develop written expectations to set
depth of knowledge to teach staff how to
the ground rules (e.g., no marketing beyond
properly use the technology. Users tend to
agreed scope). Conduct a failure mode and
first learn what they need to know to do their
effects analysis and use the results to plan the
jobs, and then all that is feasible with the
training. All training should be coordinated by
technology. This second wave of training also the pharmacy or nurse educators in
may be more effective when partnering with
collaboration with the vendor.
the vendor.
Dinoprostone dosage forms (PROSTIN E2 and CERVIDIL) confused
(17)
A PROSTIN E2 20 mg vaginal suppository
was cut in half and used in place of a
CERVIDIL 10 mg vaginal insert intended to
promote cervical ripening in a pregnant
women. The Cervidil insert provides a gradual
release of the drug and can be removed. The
suppositories, which cause tetanic
contractions, are used to evacuate uterine
contents after a missed abortion or fetal death.
In this case, fetal heart deceleration led to an
emergency C-section.
(14)
Certain procedures performed in utero may
require administering drugs directly to the
Prostin E2 should not be available on
nursing units and should only be
dispensed from the pharmacy after the
indicated use has been verified. Staff who
might encounter pregnant women should
be warned that, although the generic name
for both products is the same, Prostin E2
should only be used for intrauterine fetal
death and termination of pregnancy, not for
cervical ripening.
In utero medication administration to fetus presents unique safety challenges
October 3, 2013
Establish a process for prescribing fetal
medications (e.g., temporary record,
ISMP MedicationSafetyAlert!

QAA 3
July - September 2013
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
fetus. Because the fetus may not have a
medical record, drugs intended for the baby
are sometimes ordered on the mother’s chart.
In preparation for an intrauterine transfusion to
a fetus, a neuromuscular blocking agent was
ordered for the fetus to keep the baby still. The
medication, which had been ordered on the
mother’s chart, was administered IV to the
mother, leading to respiratory arrest. The
mother died and the infant sustained CNS
impairment.
generic record for Baby Doe using the
mother’s identifier). Avoid prescribing fetal
drugs on the mother’s record. Develop
order sets for fetal medications. Pharmacy
preparation and labeling should make it
clear that the drug is intended for the fetus.
Require a “time-out” process to verify all
information before fetal drug
administration.
No.
(18)
Errors involving 10-fold topotecan overdoses
have been reported. Several of these errors
have occurred because the decimal point in
the dose was overlooked (e.g., “.7 mg” dose
misread as 7 mg; “2.5 mg” dose misread as
25 mg) or because a trailing zero was used
after a whole number dose (“4.0 mg”
misunderstood as 40 mg).
Avoiding topotecan 10-fold overdoses
Always include a leading zero (e.g., 0.7
mg) and avoid using trailing zeros (e.g., 2
mg, not 2.0 mg) when expressing doses.
Include the intended dose in mg/m 2 and
the total calculated dose to allow other
clinicians to verify the dose. Consider the
use of standardized order sets to avoid
topotecan dosage confusion.
(16)
Several bleeding reversal products have been
referred to as “Prothrombin Complex
Concentrate” or “PCC,” but there is a new
product, KCENTRA, with the proper name of
Prothrombin Complex Concentrate. The use
of “Prothrombin Complex Concentrate” or
“PCC” may result in confusion regarding
which drug is intended.
Confusion a “factor” with “PCC” orders
Determine which of these reversal products
will be on the formulary and educate staff
about each agent and the risk of confusion
when using the terms “Prothrombin Complex
Concentrate” or “PCC.” Always clarify orders
for “Prothrombin Complex Concentrate” or
“PCC” in order to determine the specific brand
name.
(15)
Action Required/
Assignment
Date
Completed
FLEET ENEMA SALINE (dibasic and monobasic sodium phosphate) contains phosphates, not plain saline
Fleet Enema Saline contains sodium
Avoid Fleet enemas in elderly patients with
October 3, 2013
ISMP MedicationSafetyAlert!

QAA 4
July - September 2013
ISMP
(19)
Organization
Assessment
Problem
Recommendation
phosphate monohydrate 19 g and dibasic
sodium phosphate 7 g. Because the label
states “saline,” the phosphate content may be
overlooked. Phosphate toxicity is possible from
even a single enema, although elderly patients
with renal insufficiency, those using more than
one enema per 24 hours, and patients with
decreased intestinal motility are more at risk.
renal insufficiency and those with diseases
that slow intestinal motility. When used for
other patients, the enema should be
immediately expelled, and a second dose
within 24 hours should not be administered.
Patients should be warned to carefully follow
label directions and to avoid using more than
one enema in 24 hours.
No.
(15)
QuarterlyActionAgenda
Action Required/
Assignment
Date
Completed
Protecting vulnerable patients during handoffs to long-term care (LTC)
Medication errors in a LTC facility often
Establish a list of drugs that are often not
originate in the hospital. For example,
continued after hospitalization and refer to the
unnecessarily including the strength of insulin list during discharge medication reconciliation
(100 units per mL) without the actual dose on to determine if clarifications are needed.
a transfer form led a LTC nurse to
Require prescribers to verify transcribed
misunderstand a new resident’s dose as 100 discharge sum-maries, and coordinate
units, which led to his death. Studies show
completion of the transfer/ referral form with
inconsistencies between medications on
the discharge summary to ensure
discharge summaries and transfer forms,
consistency. Have pharmacists review the
leading to error rates of 21% or more during
prescribed medications for patients being
transitions between hospitals and LTC,
transferred to LTC facilities.
particularly with warfarin, insulin, opioids, and
cardiovascular drugs.
Pump resumes patient-controlled analgesia (PCA) dosing when turned off then on again
A young patient was transitioned from
If you use these pumps, disconnect the
morphine PCA, using a CADD-Solis
patient from the pump and/or remove the
Ambulatory Infusion Pump, to
medication cassette if PCA is discontinued.
oxyCODONE as needed for pain. The
Another option is to reset the PCA dose and
nurse stopped the infusion and turned the
continuous infusion rate to “zero” prior to
pump off, but left the patient connected in
shutting off the pump, so if it is turned back
case the transition from PCA was not
on, a security code is needed to modify the
tolerated. These pumps do not feature an
pump settings. You can also remove the
auto-lock function, allowing the patient to
battery pack, although this option may lead to
turn the pump back on and administer
lost batteries and delayed therapy.
bolus doses every 15 minutes.
Drug shortage leads to preparation of wrong strength of levothyroxine
(14)
A pharmacy was unable to obtain vials of
October 3, 2013
Hospitals should have a plan in place for
ISMP MedicationSafetyAlert!

QAA 5
July - September 2013
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
levothyroxine 500 mcg and ordered 100 mcg
vials instead. Upon reconstituting the drug
with 5 mL, a tech-nician failed to notice the
strength and prepared the drug as usual. He
labeled the vial as containing 100 mcg/mL but
it contained 20 mcg/mL.
how product replacements are used during
a shortage, and how changes are
communicated to staff. For additional
strategies to avoid errors during drug
shortages, visit: www.ismp.org/
Newsletters/acutecare/articles/20101007.a
sp.
No.
October 3, 2013
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 6