January – March 2013
ISMP
QuarterlyActionAgenda
Oneof themost important waystoprevent medicationerrorsistolearnabout problemsthat haveoccurredinother organizationsandtousethat informationtoprevent similar problemsat your practicesite. Topromotesuchaprocess, the
followingselecteditemsfromtheJanuary-March2013 issuesof theISMPMedicationSafetyAlert! havebeenpreparedfor aninterdisciplinarycommitteetostimulatediscussionandactiontoreducetheriskof medicationerrors. Eachitemincludesa
descriptionof themedicationsafetyproblem, recommendationstoreducetheriskof errors, andtheissuenumber tolocateadditional informationasdesired. Look for our high-alert medicationiconunder theissuenumber if theagendaiteminvolvesoneor
moremedicationsontheISMP’sList of High-Alert Medications(www.ismp.org/Tools/highalertmedications.pdf). TheActionAgendaisalsoavailablefor downloadinaMicrosoft Wordformat
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1302.doc) that allowsexpansionof thecolumnsinthetabledesignatedfor organizational documentationof anassessment, actionsrequired, andassignmentsfor eachagendaitem. ManyproductrelatedproblemscanalsobeviewedintheISMPMedicationSafetyAlert! sectionof our websiteat: www.ismp.org. Continuingeducationcredit isavailablefor nursesat: www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
Problem
No.
—ISMP high-alert medication
Organization
Assessment
NAN ALERT: KADCYLA (ado-trastuzumab emtansine) confused with HERCEPTIN (trastuzumab)
Recommendation
(5,
8)
Strong similarity between the generic
names of Kadcyla (ado-trastuzumab
emtansine) and Herceptin (trastuzumab)
may result in harmful errors given
differences in dosing and treatment
schedules. Ado-trastuzumab emtansine
may not be fully communicated or may be
misread. Certain drug information
references display the generic name of
Kadcyla without the “ado” prefix, so those
searching with this prefix may not find the
drug, potentially resulting in the inability to
prescribe it.
Alert practitioners to the risk of incomplete
presentation of the generic name of
Kadcyla in publications and information
systems. Hospital computer systems and
guidelines should employ strategies to
differentiate the names and warn against
confusion. Promote use of both the brand
and full generic names when
communicating orders on order sets or
computerized prescriber order entry
systems. For more information, view a
recent National Alert Network (NAN) Alert
at: www.ismp.org/ nan.
(2)
“Glacial” acetic acid (99.5%) has been
accidentally purchased, dispensed, and/or
applied topically during colposcopy and other
procedures, such as wound irrigations,
instead of a much more diluted acetic acid
solution (0.25% solution, 2% solution
[irrigation], vinegar [5%]). Severe pain, serious
tissue damage, third-degree burns, and in one
case, bilateral leg amputation have resulted.
NAN ALERT: Remove “glacial” acetic acid from the pharmacy
ISMP has published an Alert (www.ismp.org/
nan) through the National Alert Network
(NAN), which recommends removing glacial
acetic acid from the pharmacy and replacing it
with vinegar or a commercially available
0.25% or 2% solution. Conduct an
independent double-check in the pharmacy to
verify that the correct strength of acetic acid
has been ordered and is dispensed.
(2,
3)
Between 2010 and 2012, close to 7,000
patients may have been exposed to HIV,
Remove multiple-dose pen devices from inpatient use
Given reports of ongoing misuse of insulin
pens—in particular, ISMP believes the risk
April 18, 2013
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 1
January – March 2013
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
hepatitis B, or hepatitis C because insulin
pens were reused for multiple patients after
only changing the needle. Contamination from
retrograde blood flow into the pen after
injection is possible. Repeated warnings from
FDA, ISMP, and CDC, along with staff
education and monitoring, have not been
successful in reducing these events.
associated with cross-contamination is best
mitigated by giving consideration to removing
insulin pens from use in hospitals. The
Veterans Health Administration (VA) recently
prohibited use of multiple-dose pen devices in
VA facilities with a few exceptions
(www.ismp.org/sc?id=161). ISMP urges other
hospitals to follow suit.
No.
(4)
While ISMP stands behind its
recommendation for hospitals to consider
transitioning away from insulin pen use,
simply replacing insulin pens with insulin vials
may result in errors. Staff accustomed to
using insulin pens may have knowledge
deficits about withdrawing insulin doses from
a vial. The U-100 designation on insulin vials
has been misunderstood to mean 100 units
per vial, leading to overdoses. The dose in
units has been measured in mL by staff
unfamiliar with the differences between an
insulin syringe and other parenteral syringes.
Insulin vials often look alike, leading to mixups. Insulin doses drawn into syringes also
run the risk of being unlabeled.
(1,
2)
In an ISMP survey, up to 29% of pharmacy
technicians reported that contamination of
compounded sterile products has happened
in their facility during the past year. Only half
(50%) of staff pharmacists were confident
that contamination had not occurred. A
governor-commissioned report in MA on
sterile compounding recommends stronger
oversight and licensure of compounding
pharmacies and calls for pharmacy boards to
review compounding activities in hospitals
April 18, 2013
Action Required/
Assignment
Date
Completed
Safe use of insulin vials
Before transitioning away from insulin pens,
conduct a failure mode and effects analysis
(FMEA) to proactively address problems that
are sure to arise. Reeducate staff regarding
injection techniques and measuring doses
with insulin syringes. Wherever possible,
pharmacy should prepare, label, and
dispense daily patient-specific basal insulin.
For rapid-acting insulin, vials (3 mL preferred)
should be dispensed and labeled for specific
patients. Provide insulin syringes in
appropriate sizes (1 mL, ½ mL, 0.3 mL) to
areas where insulin may be administered and
in hyperkalemia treatment kits.
Review of sterile compounding practices
Hospitals should use the Proceedings
from the ISMP Sterile Preparation
Compounding Safety Summit:
Guidelines for Safe Preparation of
Sterile Compounds
(www.ismp.org/Tools/guidelines/IVSummit/
IVCGuidelines.pdf) as a resource to
identify opportunities for improvements in
sterile compounding practices in hospitals.
ISMP MedicationSafetyAlert!

QAA 2
January – March 2013
ISMP
Problem
No.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
and other locations such as physician
offices.
(6)
Drawn curtains, muted alarms, and diverted attention lead to death in the postanesthesia care unit (PACU)
A teen died following a tonsillectomy after
Maintain a direct line of sight to patients.
receiving a dose of IV fentaNYL in the PACU. Provide staffing to ensure proper
Staff identified several causes: 1) After
monitoring, especially when IV opioids are
receiving fen-taNYL, the patient was not
administered. Manage alarm hazards by
observed or assessed for 25 minutes due to
preparing an annual inventory of device
an emergency with another patient; 2) The
alarms, identifying the most important
alarms on the monitoring equipment had
alarms, establishing policies for managing
been muted due to alarm fatigue; and 3) A
alarms, and educating staff about alarm
curtain had been drawn around the patient,
policies and procedures. Additional
obstructing the view necessary to maintain an strategies can be found in the full article at:
ongoing visual assessment of the patient.
www.ismp.org/sc?id=175.
(1)
Westward’s 1 mL vials of
HYDROmorphone 2 mg/mL and morphine
5 mg/mL may increase the risk of mix-ups
between these two drugs due to similar
looking vials, especially once the caps are
removed.
(4)
A young patient with acute promyelocytic
leukemia (APL) was supposed to receive
oral tretinoin (all-trans retinoic acid
[ATRA]), but an oncology nurse enrolled
the patient and prescriber in the iPledge
program and called a prescription for
ISOtretinoin in to a local pharmacy. The
error was found 4 months later when the
April 18, 2013
Look-alike vials of HYDROmorphone and morphine (Westward)
Do not dispense these vials together to the
same patient care area. If possible,
dispense only unit dose syringes of these
medications. If vials must be dispensed,
purchase one of the products from a
different manufacturer to help differentiate
the vials.
Tretinoin confused with ISOtretinoin
This type of error associated with similar
drug names is best prevented with the use
of a well-designed order set for APL,
highlighting that tretinoin (and not
ISOtretinoin) should be prescribed.
Referring to the drug as all-trans retinoic
acid rather than tretinoin may help
differentiate it from ISOtretinoin; however,
ISMP MedicationSafetyAlert!

QAA 3
January – March 2013
ISMP
Problem
No.
patient was admitted to the hospital.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Date
Completed
use of the acronym ATRA alone is
discouraged.
(4)
A patient died after receiving oral liquid
niMODipine via a central IV line instead of a
nasogastric (NG) tube. The pharmacy,
unaware the drug was being given via an NG
tube, dispensed capsules, the contents of
which were withdrawn into a syringe with a
needle and diluted. The drug was accidentally
administered IV, resulting in severe
hypotension and cardiac arrest.
Oral niMODipine liquid administered IV
Pharmacy should prepare all doses of
enteral or oral liquid niMODipine. A study
provides evidence that the liquid extracted
from capsules, stored in amber oral
syringes, and placed in light-protected
bags, is stable at room temperature for 31
days. A mechanism should be established
to alert pharmacy to NG, orogastric, or
percutaneous gastric tubes.
(3)
Due to the national shortage of sodium
bicarbonate injection, hospitals have been
dispensing sodium acetate injection as an
alternate alkalinizing agent. Accidentally
substituting potassium acetate in dosages
commonly used for sodium acetate (e.g.,
40 mEq or more) could prove fatal.
Focusing on the acetate component of
potassium acetate and failing to recognize
the potassium component has been one
underlying cause of such errors.
Potassium and sodium acetate injection mix-ups
Proactive risk-reduction strategies must be
identified and implemented when using
alternative products during a drug shortage. If
used, potassium acetate should be stored in
an isolated, designated area, and pharmacy
staff should be educated about the unique
location of the product and the related safety
issue. If available, use pharmacy workflow
software with barcode scanning capability to
prevent mix-ups between sodium acetate and
potassium acetate.
(6)
A nurse gathering a drug history on a new
patient inadvertently selected methadone 100
mg BID from the computer screen instead of
metoprolol 100 mg BID. The physician
reviewed the medication list and continued all
the medications. The pharmacist questioned
Metoprolol mistaken as methadone on computer screen
Use tall man letters to distinguish these two
drugs in computer listings. Require
prescribers to specify the indication if
methadone is prescribed. If the patient is
being treated for opioid addiction, confirm the
dose with a methadone clinic. Have the
April 18, 2013
Action Required/
Assignment
ISMP MedicationSafetyAlert!

QAA 4
January – March 2013
ISMP
Problem
No.
the high methadone dose, but the physician
instructed to give the medication as written.
After receiving 2 doses, the patient
experienced a cardiorespiratory arrest.
(1)
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
patient/caregiver confirm (even sign) the
medication reconciliation list to verify
accuracy. All questionable orders must be
fully resolved before dispensing and
administering the medication.
Acetaminophen suspension (PrecisionDose) labeling could lead to pediatric overdoses
The word “Children’s” is on the container
PrecisionDose was made aware of the
labels of 325 mg and 650 mg unit dose cups
problem and is looking into the matter. For
of acetaminophen oral suspension
children, pharmacy should dispense patient(PrecisionDose). This implies that the total
specific doses of acetaminophen suspension
dose in the cup is suitable for children.
in oral syringes. The unit dose cups should
Depending on the child’s age and weight, 325 only be dispensed if the child’s dose is the
mg or 650 mg might represent an overdose.
total dose in the cups.
(4)
Because certain people experience
impairment of alertness in the morning after
taking zolpidem, FDA has asked
manufacturers to lower the recommended
dose for women from 10 mg to 5 mg for
immediate-release and from 12.5 mg to 6.25
mg for the extended-release products.
Consideration of these lower doses is
recommended for men as well.
(3)
With a shortage of methylPREDNISolone
sodium succinate in 40 mg and 125 mg vials,
SOLU-MEDROL 500 mg vials have been
used. Two formulations are available and
packaged in similar looking cartons. The ActO-Vial of Solu-MEDROL provides 500 mg/4
mL once the diluent in the chamber is mixed
with the lyophilized powder. The other SoluMEDROL product, which provides only the
powder, results in 500 mg/8 mL after dilution
according to the labeling. The differing
strengths could lead to dosing errors.
April 18, 2013
Reduce zolpidem (AMBIEN and generics) dose in order sets
If zolpidem (Ambien and generics) is
included on order sets, ensure that the
doses are adjusted accordingly. Have
pharmacy screen orders for zolpidem to
monitor adherence to the new FDA dosing
recommendation.
Solu-MEDROL (methylPREDNISolone) dose confusion
ISMP spoke with Pfizer about our concerns
and encouraged the company to make
these packages look different. When
possible, stock only one of the two
available formulations of Solu-MEDROL. If
a change in the formulation or strength is
required due to ongoing shortages, affix
auxiliary labels to vials to alert staff to the
new concentration after dilution.
ISMP MedicationSafetyAlert!

QAA 5
January – March 2013
ISMP
April 18, 2013
QuarterlyActionAgenda
ISMP MedicationSafetyAlert!

QAA 6