April - June 2008
ISMP
QuarterlyActionAgenda
One of the most important ways to prevent medication errors is to learn about problems that have
occurred in other organizations and use that information to prevent similar problems at your practice
site. To promote such a process, the following selected agenda items have been prepared for your senior
leaders and an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication
errors. These agenda items appeared in the ISMP Medication Safety Alert! between April and June 2008. Each
item includes a brief description of the medication safety problem, recommendations to reduce the risk of
errors, and the issue number in parentheses to locate additional information as desired. Look for our highalert medication icon under the issue number if the agenda item involves one or more medications on the ISMP
List of High-Alert Medications. Many product-related problems can be viewed in the ISMP Medication Safety
Alert! section of our website. The Action Agenda is also available for download in a Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda0803.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/Newsletters/acutecare/actionagendas.asp.
Key:
Problem
No.
(7)
In 1999, label changes
were made to highlight
the total amount of drug
available in Cerebyx
vials after fatalities
resulted from confusing
the per mL concentration
as the total dose in the
vial. Despite label
changes, FDA has
identified seven more
fatalities of children
who received 10-fold
overdoses of Cerebyx. In
four cases, the drug was
obtained from an
automated dispensing
cabinet (ADC). In two
cases, the per mL
concentration (50 mg
July 17, 2008
— ISMP high-alert medication
Recommendation
Organization
Action Required/
Assessment
Assignment
Medication errors associated with CEREBYX (fosphenytoin)
Date Completed
ADC screens, shelf labels,
and printed requisitions
should display the total
drug content per container
instead of the concentration
per mL. Ensure all written
information is consistent
with the manufacturer’s
label (100 mg PE/ 2 mL, or
500 mg PE/10 mL). Pediatric
facilities should consider
stocking only 100 mg PE/2 mL
vials of Cerebyx in the
emergency department. The
need to retrieve many vials
in order to prepare a single
dose (i.e., ten 2 mL vials
would be needed to prepare a
1,000 mg PE dose versus just
two 10 mL vials) may serve
ISMP MedicationSafetyAlert!

QAA 1
April – June 2008
ISMP
Problem
No.
PE/mL) was listed on the
ADC screen, not the
total drug in the vial
(500 mg PE/10 mL).
(10
)
(10
)
(12
)
The current situation
with heparin products and
back-orders means that
hospitals may be
receiving heparin in
quantities, strengths,
and packaging that are
unfamiliar to staff. The
possibility of
significant dosing errors
increases when unfamiliar
products are stocked.
A fatal error occurred
when a pregnant woman
was given a prescription
for propylthiouracil,
abbreviated as “PTU,”
early in her pregnancy
but received Purinethol
when the prescription
was filled. A second
patient experienced
liver toxicity when a
prescription for
propylthiouracil, also
written as “PTU,” was
dispensed as Purinethol.
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
to alert practitioners to a
possible dosing error.
Recall of heparin leads to use of unfamiliar concentrations
Barcode scanning is the best
defense against mix-ups
arising from unfamiliar
products. Use auxiliary
labels to call attention to
unusual strengths—even
circling the concentration
on vial labels with a pen.
Vials of heparin flush
solutions should be
separated from vials
containing therapeutic
concentrations.
Mix-ups with propylthiouracil and PURINETHOL (mercaptopurine)
The dangerous abbreviation
“PTU” should not be used.
Physicians should be encouraged
to list brand and generic names
on orders for Purinethol, and
to include the purpose when
prescribing either drug.
Computer order entry system
warnings should be installed
for both drugs. Do not store
Purinethol and propylthiouracil
near each other. Consider
placing warning labels on
product containers.
Caution regarding color-coded eye meds
(8)
The American Academy of
Ophthalmology has long
endorsed a voluntary
color-code scheme for
ophthalmic products
based on therapeutic
July 17, 2008
Color-coding ophthalmic
products according to
therapeutic class does not
decrease medication mix-ups
in hospitals, as it might in
a patient’s home. To prevent
ISMP MedicationSafetyAlert!

QAA 2
April – June 2008
QuarterlyActionAgenda
Problem
No.
class. But the color
schemes are too similar
to differentiate between
classes of eye
medications, and
numerous product mixups, both between and
within each class, have
been reported.
ISMP
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
look-alike problems,
pharmacy purchasers should
avoid awarding contracts to
one vendor for an entire
product line and should
consider purchasing drugs
within a class from
different manufacturers.
Strength misread as total dose on mannitol IV bags (B. Braun)
(8)
The labeling on 250 mL
bags of IV mannitol 20%
states, “Each 100 mL
contains: Mannitol USP
20 g in Water for
Injection USP.” A
physician prescribed
three bags for a
patient, believing each
one delivered just 20 g.
Each 250 mL bag actually
contains 50 g.
Consider affixing alert
stickers to mannitol to
inform staff about the total
amount of drug in each bag.
Review other medication
labels for potential errors,
and affix warning stickers
or other visual cues to
communicate the total
content of medication in
each container.
Safety issues with insulin pens used in hospitals
(9)
Errors arising from the
adoption of insulin pen
devices in healthcare
organizations are
emerging: needlestick
injuries to healthcare
workers; sharing pens
among different
patients; withdrawing
medication from pens,
which results in air
pockets that can
interfere with dosing
accuracy; inadvertent
product mix-ups; and
erroneous dosing due to
July 17, 2008
Although insulin pens offer
many advantages over insulin
vials, safe use requires
anticipating and reducing
potential risks before
implementation and close
monitoring during the first
few months of implementation
when unanticipated failures
and workarounds are most
likely to occur. Conducting
a failure mode and effects
analysis before use,
limiting the variety of pens
in use, educating staff
before use, and establishing
ISMP MedicationSafetyAlert!

QAA 3
April – June 2008
ISMP
Problem
No.
improper drug
administration
techniques.
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
written guidelines for
reference are important risk
reduction strategies.
Avoid confusion with TORISEL (temsirolimus) dose preparation
(9)
Torisel injection is
distributed in a kit
that contains a vial of
active drug along with a
vial of diluent.
Following dilution, the
pre-printed strength on
the vial is no longer
accurate. A 20% overfill
(that is not explicitly
stated on the label)
adds complexity and
increases the potential
for dosing errors.
(9)
Inadvertently storing
one insulin product
inside of the external
carton of another type
of insulin can lead to
serious wrong-drug
errors.
(9)
Sumatriptan 25 mg
tablets were placed into
a matrix drawer intended
for sitagliptin 25 mg
tablets in an automated
dispensing cabinet
(ADC). Both medications
are manufactured in 25,
50, and 100 mg tablets,
and the generic names
are similar when read
July 17, 2008
Pharmacists should keep the
package insert, with full
instructions for dilution,
with both the active drug
and diluent vials. Use
pharmacy computer alerts
during order entry and/or
warning stickers on
packaging to notify staff
about the change in
concentration when preparing
the final dilution. For more
information, visit:
www.ismp.org/sc?k=pbm.
Remove insulin vials from cartons
External cartons for insulin
products should be discarded
prior to dispensing the
vials or at the time of
receipt on the nursing unit.
Sumatriptan (IMITREX) confused with sitagliptin (JANUVIA)
Be alert for potential mixups with this look-alike,
sound-alike pair. Use of a
bar-coding system when
replenishing ADC stock
diminishes the risk of
inadvertent drug mix-ups.
Add a redundancy to manual
checking processes by having
stocking personnel match
both the generic and brand
ISMP MedicationSafetyAlert!

QAA 4
April – June 2008
QuarterlyActionAgenda
Problem
No.
and pronounced.
(10
)
Hospitals may not manage
the process by which
pharmaceutical products,
devices, and related
education are brought
into their organizations
to maximize safety.
Unexpected
pharmaceutical products
(including samples) and
changes in drug storage
have given rise to
serious, preventable
errors.
ISMP
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
names (if available) when
refilling matrix drawers.
Managing visits from pharmaceutical sales representatives
If you allow onsite visits
by pharmaceutical
representatives, require
them to schedule visits with
the pharmacy, wear an
identification badge, sign
an agreement to abide by
hospital rules—including no
sample distribution, and be
escorted to their
destination. For details,
visit:
www.ismp.org/Newsletters/acu
tecare/articles/20080522.asp
.
Red rules in healthcare
(10
)
(12
)
In highly reliable
industries, “red rules”
are limited to just a
few rules that must
always be followed to
prevent serious harm to
employees, customers, or
the product line. In
healthcare, red rules
should not be confused
with policies or
standard operating
procedures—even crucial
ones like handwashing
that call for strict
adherence. While
compliance with policies
and procedures is always
expected, there will
July 17, 2008
Red rules should be limited
to a few, well understood
and memorable rules that are
possible and desirable for
everyone to follow under all
circumstances. Anyone who
notices that a red rule has
been breached should have
the authority to stop the
process. Examples of red
rules in healthcare might
include a time out before an
invasive procedure and
reconciliation of a sponge
count before closing a
surgical incision. Following
the “5 rights” of medication
use and full compliance with
barcode scanning technology
ISMP MedicationSafetyAlert!

QAA 5
April – June 2008
QuarterlyActionAgenda
Problem
No.
(11
)
(11
)
ISMP
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
inevitably be
are not appropriate red
circumstances when
rules in healthcare, as both
practitioners cannot
rules are often broken for
abide by the rules, or
reasons rooted in inadequate
circumstances where
system support for following
violating a rule may be
the rule.
the best course of
action.
Restricted character space and truncated drug listings are a set-up for medication errors
Truncated information
Review how drug information
appeared on a medication
appears on MARs and pharmacy
administration record
labels. If problems are
(MAR) as “NOVOLOG
found, work with the
FLEXPEN 70” rather than
pharmacy computer system
“NOVOLOG FLEXPEN 70/30.”
vendor to prevent truncated
This led a nurse to
data from appearing on MARs
administer 70 units of
and labels. Including “Mix”
NOVOLOG (insulin aspart)
with NOVO-LOG MIX 70/30
instead of NOVOLOG 70/30
(which is the actual brand
(insulin aspart
name) can help differentiate
protamine, insulin
the drug from NovoLog.
aspart).
Identify home medications
A patient filled
The original medication
prescriptions for
error was a causative factor
ISENTRESS (raltegravir)
in the need for inpatient
400 mg, one tablet BID,
care, and his condition
and PREZISTA (darunavir)
continued to worsen until
300 mg, two tablets
the error was discovered and
twice daily. The labels
rectified. Pharmacists must
on the prescription
identify—very early on—any
bottles were reversed,
medication brought from home
so he took incorrect
by patients, especially if
doses for a month. He
it’s necessary to use the
was admitted to the
patient’s home medication
hospital where the error
supply until the hospital
persisted because his
pharmacy can obtain the
home medications were
drug(s).
administered according
to the misplaced labels.
July 17, 2008
ISMP MedicationSafetyAlert!

QAA 6
April – June 2008
ISMP
Problem
No.
(12
)
(12
)
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
Prevent dangerous drug-device interaction causing falsely elevated glucose levels
When patients receive
Hospitals should consider
EXTRANEAL (icodextrin)
using only POC blood glucose
peritoneal dialysis
meters that rely on glucose
solution, blood glucose
oxidase, glucose hexokinase,
values obtained using
glucose dehydrogenase
some point-of-care (POC)
nicotinamide adenine
glucose meters may be
dinucleotide (GDH-NAD), or
falsely elevated. Deaths
flavin adenine dinucleotide
have been reported due
glucose dehydrogenase (FADto severe hypoglycemia
GDH), which are accurate
after prescribing
even in the presence of
insulin based on the
interfering products
falsely elevated glucose
including maltose. If other
levels. MaltosePOC meters are used, screen
containing IV
patients for interfering
immunoglobulin (IVIG)
products and, if they are
products may cause
prescribed, obtain glucose
similar falsely elevated
levels using hospital
glucose values with
laboratory methods only.
glucose meters.
Look-alike glass bottles of sodium chloride and nitroglycerin
Sodium chloride 0.9%
Evaluate and correct storage
injection was
practices that can lead to
administered instead of
errors. Determine if at-risk
IV nitroglycerin when
behaviors (such as “grab and
similarly appearing
go” when selecting products)
glass bottles were
are occurring on busy units.
stored beside one
Practice habits—such as
another in a busy ED.
meticulous reading of labels
and consistent use of
barcode technology—should be
operational norms that are
periodically monitored.
July 17, 2008
ISMP MedicationSafetyAlert!

QAA 7