April – June 2011
ISMP
QuarterlyActionAgenda
Oneof themost important ways toprevent medication errors is tolearn about problems that haveoccurred in other organizations and tousethat information toprevent similar problems at your practicesite. To promotesuch aprocess,
thefollowing selected items fromthe April-June2011 issues of theISMPMedication Safety Alert! havebeen prepared for an interdisciplinary committeetostimulate discussion and action toreducetherisk of medication errors. Each itemincludes a
description of themedication safety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional information as desired. Look for our high-alert medication icon under theissuenumber if theagendaiteminvolves
oneor moremedications on theISMPList of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). TheAction Agendais alsoavailablefor download in aWord format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1103.doc) that allows expansion of thecolumns in thetabledesignated for organizational documentation of an assessment, actions required, and assignments for each agendaitem. Many
product-related problems can alsobeviewed in theISMPMedication Safety Alert! section of our websiteat: www.ismp.org. Continuing education credit is availablefor nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp.
Key:
Problem
No.
(13)
(7,
8,
13)
—ISMP high-alert medication
Recommendation
Organization
Assessment
Dosing confusion with colistimethate sodium for injection
Action Required/
Assignment
Date Completed
ISMP and ASHP sent a warning
Dose colistimethate sodium ONLY as
through the National Alert Network
colistin base, with a dosage reduction
(NAN) about dosing errors involving
for renal insufficiency. Consider
colistimethate sodium for injection, a
restricting ordering to infectious
prodrug of colistin with a high
disease specialists or intensivists.
potential to induce nephrotoxicity and
Use pre-approved guidelines or order
neurotoxicity. The drug is used to
sets with colistin base dosing only.
treat multidrug-resistant organisms.
Dose limits should be established with
The strength of colistimethate sodium immediate investigation required for
is labeled in terms of the colistin base, doses outside hospital guidelines.
not the prodrug. Recently, a physician The full NAN alert can be accessed
ordered the dose as the prodrug, but
at: www.ismp.org/sc?k=nanalerts.
the dose was dispensed as colistin
base, which resulted in an overdose.
Parenteral nutrition-related deaths and a cluster of bacterial endophthalmitis call for compounding pharmacy oversight
Nineteen patients received
The use of compounding pharmacies
parenteral nutrition (PN) containing
for com-plex solution preparation
Serratia marcescens. Nine patients
should not cease as a result of these
died. All of the PN came from the
outbreaks. Compounding pharmacies
same compounding pharmacy. A
are often better equipped to employ
shortage of commercial amino acid
and monitor compliance with USP
solutions this winter led the
<797>. Hospitals should use
pharmacy to use amino acid
commercially available solutions
powder. A failure in the sterilization
when possible. If solutions are
process caused the contamination.
outsourced, regularly monitor the
Also, a cluster of bacterial
external vendor using ASHP’s new
endophthalmitis occurred related to
Outsourcing Sterile Products
intravitreal injections of
Preparation: Contractor
July 28, 2011
ISMP MedicationSafetyAlert!

QAA 1
April – June 2011
ISMP
Problem
No.
bevacizumab obtained from another
compounding pharmacy. Not using
masks, talking during preparation of
the injections, and no vertical barrier
were suspected to be sources of
contamination.
(9)
Broselow Pediatric Antidotes for
Chemical Warfare Tape
(www.ismp.org/sc?k=broselow)
resembles the Broselow Pediatric
Emergency Tape. There could be
confusion between the two tapes during
a pediatric emergency.
(11)
A recent pharmacy compounding
error involved a small volume
injectable preparation in which a
woman in labor received
succinylcholine instead of
ePHEdrine after a technician with
multiple drugs under the hood during
preparation of the medication
syringes mixed up the two products.
Another error involved an IV
admixture in which an infant
received a highly concentrated
solution of sodium chloride after a
technician pulled what he thought
was a 250 mL bottle of sterile water
to use as a base solution, but it was
actually a bottle of 23.4% sodium
chloride.
(10)
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
Assessment Tool (www.ashpfoun
dation.org/MainMenuCategories/
PracticeTools/SterileProductsTool.as
px). Better FDA and licensing
oversight for these pharmacies are
also needed.
Broselow tape for chemical warfare may be confused with the emergency tape
Make staff aware that both tapes exist.
Guard against confusion by underlining
the words “Chemical Warfare” and storing
this tape on carts in the emergency
department only, in a different part of the
cart than the emergency tape.
Safe practices in pharmacy sterile compounding areas
Limit in-house preparation of
injectables and solutions to products
not available commercially. Separate
the storage of concentrated bulk
solutions, particularly concentrated
electrolytes, amino acids, and
dextrose. Have a pharmacist pull the
necessary ingredients prior to
preparation to give to technicians.
Use an automated compounder when
possible. Place the ingredients of only
one product under the hood at a time.
Establish a standard procedure for
verifying products, preferably
checking additives before mixing
high-alert medications.
Final Acute Care Guidelines for Timely Administration of Scheduled Medications posted on ISMP website
Nurses who responded to an ISMP
ISMP has posted the final Acute Care
survey made it clear that changes in Guidelines for Timely Administration
the drug administration system have of Scheduled Medica-tions at:
made the long-standing Centers for
www.ismp.org/tools/guidelines/acute
Medicare & Medicaid Services
care/tasm.pdf. The guidelines
July 28, 2011
ISMP MedicationSafetyAlert!

QAA 2
April – June 2011
ISMP
QuarterlyActionAgenda
Problem
Recommendation
(CMS) “30-minute rule” error prone.
Nurses reported taking shortcuts to
comply with the rule, which have led
to errors, some harmful. Examples
include skipping pre-medication
assessments and double checks,
pre-pouring medications, borrowing
medications, and failing to use
available bar-coding technology.
ISMP has been working towards
documentation of what we believe
represents best practices
associated with timely
administration of scheduled
medications.
suggest that hospitals should define a
short list of time-critical scheduled
medications that should be
administered within 30 minutes of the
scheduled time. For non-time-critical
medications, administer daily, weekly,
or monthly medications within 2 hours
of the scheduled time, and drugs
prescribed more frequently than daily
(but not more often than every 4
hours) within 1 hour of the scheduled
time. For now, hospitals will still be
held accountable to CMS for the “30minute rule,” although we anticipate
that changes will be forthcoming.
No.
(9)
FDA continues to receive reports of
methemoglobinemia
(www.fda.gov/Safety/MedWatch/Saf
ety
Information/SafetyAlertsforHumanM
edicalProducts/ucm250264.htm), a
serious and potentially fatal adverse
effect associated with topical
benzocaine products, including
sprays used to numb mucous
membranes before procedures and
over-the-counter gels and liquids
used to relieve pain from teething,
canker sores, and gum irritation.
(13)
Regardless of whether a correct or
incorrect product or patient has
been scanned, audible barcode
scanners produce the same
beeping sound. The nurse must
confirm whether he/she scanned
the correct patient/medication by
reading the actions on the
July 28, 2011
Organization
Assessment
Action Required/
Assignment
Date Completed
Benzocaine risk of methemoglobinemia
Screen patients who may receive
topical benzocaine for risk factors
(e.g., G6PD deficiency). Avoid sprays
of longer duration than recommended
on the label. When possible, use
metered-dose sprays. Monitor
patients who receive benzocaine
sprays for signs of
methemoglobinemia during the
procedure and for 2 hours postapplication. Additional
recommendations can be found at the
FDA link to the left.
Overreliance on a barcode scanner beep can lead to errors
Identify and remedy conditions that
may result in absent or poor visibility
of the full eMAR during the entire
medication administration process,
including the scanning process.
Scanners that incorporate their own
self-contained internal logic may be
employed so nurses can view alerts
ISMP MedicationSafetyAlert!

QAA 3
April – June 2011
ISMP
Problem
No.
electronic medication administration
record (eMAR) or hand-held
scanner screen. Some nurses have
mistakenly relied on the sound of
the beep alone to signal verification
of the patient and medication.
(13)
The purpose of barcode scanning is
defeated when it occurs after drug
administration—a practice called
back scanning, which is one of the
observed workarounds used to
reduce workload during the drug
administration process. Employing
this workaround increases the risk of
wrong drug, wrong dose, wrong
time, wrong route, and wrong patient
errors.
(8)
An infant died after receiving a PN
solution that contained 60 times
more sodium than prescribed. A
pharmacy technician entered the
dose of calcium (“982” mg) into the
mEq field for sodium instead of the
correct dose of 14.7 mEq. A sodium
dose warning did not appear while
entering the order because it had
either been entered into a non-PN
template without dose limits or
entered using an adult template. A
free-text label that listed the sodium
content as 14.7 mEq was placed
over the compounder label,
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
associated with scanning, although
the entire eMAR may not be
viewable. Educate users not to rely
on the audible beep to verify the
patient/medication.
Barcode scanning after drug administration has little value
Hospitals should monitor for back
scanning practices, identify the
causes if it occurs, and make the
necessary system changes to avoid
this practice, including but not limited
to educating nurses about the risks
associated with back scanning. If a
drug must be given under urgent
conditions, the safest method is to
scan the patient and medication
barcodes, and create a new task on
the electronic medication
administration record (eMAR) to
document the drug administration,
which must be later verified.
Parenteral nutrition (PN) calcium dose entered as sodium dose, leading to infant’s death
July 28, 2011
Synchronize the order and format of
ingredients listed in PN order sets,
the pharmacy computer system, the
compounder software, and the PN
label to help prevent errors. If your
PN software supports dose warning
limits, fully implement them but do
not rely on them only. Define and
install more restrictive weight-based
dosing limits applicable to specific
patient populations. Use product
labels that include the actual dose/
strength of the base solution and
each additive. Conduct verification
processes in the pharmacy to ensure
ISMP MedicationSafetyAlert!

QAA 4
April – June 2011
ISMP
Problem
Recommendation
contributing to a failure to detect the
error during product verification.
appropriateness and accuracy of the
PN order, additives, and the final PN
product, including the expected
versus actual weight.
No.
(10)
(9)
(9)
QuarterlyActionAgenda
Organization
Assessment
Action Required/
Assignment
Date Completed
PENTACEL (Diphtheria and Tetanus Toxoids, Acellular Pertussis, Poliovirus, Haemophilus b conjugate vaccine [DTaP-IPV and ActHIB])
Numerous infants did not receive the Pharmacies should dispense the two
Haemophilus influenzae type b
vials together using a rubber band or
component of PENTACEL, a twoby placing the two vials in a ziplock
part vaccine packaged in cartons
bag. Affix an auxiliary label to the
containing vials of liquid DTaP-IPV
carton to remind staff to use both
and vials of lyophilized Haemophilus vials. To confirm administration of
influenzae. Nurses administering the both components, staff should
two-part vaccine failed to use the
document the NDC number for each
DTaP-IPV component to dilute and
vial in the vaccine log before
mix with the lyophilized ActHIB
administration. Documenting the
powder component of the vaccine.
actual administration of the vaccine
should always occur after it is given.
Inconsistent use of smart pump libraries may lead to legal concerns
Clinicians sometimes view the dose
Available smart pump technology
checking feature of smart pumps as
should be fully maximized and
an option that can be turned off, or
employed consistently, and alerts
they may bypass alerts without
issued by the technology should be
consideration. Serious errors may
addressed before administering
result. From a legal perspective,
parenteral therapy. For assistance
when this technology is available but with these formidable tasks, see
not used, litigation could be
ISMP guidelines for safe
successful in finding fault with
implementation and use of smart
nurses (Harding AD, et al. Nurses’
pumps at:
risk without using smart pumps.
www.ismp.org/Tools/guidelines/smart
JONAS Healthc Law Ethics Regul.
pumps/default.asp.
2011;13(1):17-20).
Serious interaction between simvastatin and ketoconazole demonstrates a series of latent failures
A serious interaction between
Ensure that pharmacy computer
simvastatin and ketoconazole
systems warn about this serious
harmed a patient. Concomitant use
interaction and require action on the
of these drugs increases the risk of
part of the pharmacist if both drugs
rhabdomyo-lysis. The interaction
remain on the patient’s profile.
was not detected due to a series of
Encourage practitioners who
July 28, 2011
ISMP MedicationSafetyAlert!

QAA 5
April – June 2011
ISMP
Problem
Recommendation
latent failures including inactive
prescriptions that were refilled and a
temporary suspension of the
pharmacy computer alert system
during transition to an electronic
record system.
investigate events to always look for
multiple latent system failures and
multiple human errors (active failures)
that might have occurred.
No.
(13)
QuarterlyActionAgenda
FDA recently alerted the public
about mix-ups between risperiDONE
and rOPINIRole, some involving
patients who required
hospitalization. The causes of
confusion include: name similarity;
illegible written prescriptions; similar
product strengths, dosage forms,
and dosing intervals; storage next to
each other; and appearance
together in computer listings.
July 28, 2011
Organization
Assessment
Action Required/
Assignment
Date Completed
Mix-ups between risperiDONE (RISPERDAL) and rOPINIRole (REQUIP)
When prescribing either drug, the
drug name should be printed, and the
purpose of the drug should be listed.
In pharmacies, the products should
not be stored near each other, and tall
man letters should be used for
storage labeling and computer
listings.
ISMP MedicationSafetyAlert!

QAA 6