January – April 2013
ISMP
AmbulatoryCare ActionAgenda
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 agenda items have been prepared for you and your staff to stimulate discussion and collaborative action to reduce the risk of medication errors. These agenda topics appeared in
the ISMP Medication Safety Alert! Community/Ambulatory Care Edition between January 2013 and April 2013. Each itemincludes a brief description of the medication safety problem, recommendations to reduce the risk of
errors, and the issue to locate additional information. The Action Agenda is also available for download in a Word format at: www.ismp.org/Newsletters/ambulatory/actionagenda.asp. To learn how to use the ISMP Ambulatory
Care Action Agenda at your practice site, visit www.ismp.org/newsletters/ambulatory/How_To_Use_AA.asp.
Issue
04/13
03/13
02/13
May 2013
Problem
Recommendation
Organization Assessment
Action Required/ Assignment
NAN ALERT: KADCYLA (ado-trastuzumab emtansine) confused with HERCEPTIN (trastuzumab)
Strong similarity between the generic Alert practitioners to the risk of
names of Kadcyla (ado-trastuzumab
incomplete presentation of the generic
emtansine) and Herceptin
name of Kadcyla. Computer systems
(trastuzumab) may result in harmful
and guidelines should employ
errors given differences in
strategies to differentiate the names
indications, dosing, and treatment
and warn against confusion. Promote
schedules. Certain drug information
use of both the brand and full generic
references may display the generic
names when communicating orders
name of Kadcyla without the “ado”
on order sets or computerized
prefix, so those searching with this
prescriber order entry systems. ISMP
prefix may not find the drug, which
has contacted the major drug
could lead to prescribers potentially
information vendors who are
prescribing the wrong drug and
addressing this issue. For more
pharmacists selecting the wrong
information, view the National Alert
drug.
Network (NAN) Alert at:
www.ismp.org/nan.
PriLOSEC (omeprazole) - PROzac (FLUoxetine) mix-ups
We continue to get reports of mixAdd a drug-name alert in computer
ups with PriLOSEC and PROzac.
order entry systems. Use tall man
lettering (i.e., PriLOSEC and
Similar looking and sounding drug
PROzac) on computer screens and
names as well as overlapping
dosage strengths (i.e., 10, 20, and
warning labels in storage areas.
40 mg) contribute to the confusion. A Verify the indication of the medication
long-term care pharmacy received
with the patient or prescriber and
an order via fax for “Prilosec 20 mg.” check the patient’s profile before
Pharmacy staff misinterpreted the
dispensing. Prescribers should
order as “Prozac 20 mg” and sent
include the indication of the
PROzac to the long-term care facility medication on the prescription and
where the error was caught. In other should use both brand and generic
cases, patients took the wrong
names when prescribing these drugs.
medication for days or weeks.
Don’t confuse levothyroxine (T4; SYNTHROID) with liothyronine (T3; CYTOMEL)
A child diagnosed with congenital
These two drugs are similarly named,
hypothyroidism received liothyronine
have been available for decades, and
instead of levothyroxine. The child
several references warn against
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

Date Completed
ACAA 1
January – April 2013
ISMP
Issue
May 2013
Problem
developed significantly abnormal
laboratory values including a
significantly elevated T3 level
(greater than 500 nanograms/dL).
The prescription was written as “Lthyroxine,” which apparently was
confused as liothyronine (T3).
AmbulatoryCare ActionAgenda
Recommendation
confusion. Review any safeguards
you may have in place to avoid their
confusion and consider adding an
alert in your computer system
detailing the potency difference
between these drugs.
Organization Assessment
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

Action Required/ Assignment
Date Completed
ACAA 2
January – April 2013
ISMP
02/13
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 patient was admitted to the
hospital.
Recommendation
Organization Assessment
Tretinoin confused with ISOtretinoin
Use 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, use of the
acronym ATRA alone is discouraged.
This error highlights the importance of
requiring the pharmacist filling this
prescription to know the patient’s
diagnosis and the drug’s clinical
indication at the time the prescription
is filled.
02/13
We continue to hear about errors
involving non-reconstituted antiinfectives that were dispensed from
community pharmacies. One event
involved a young boy who was
prescribed amoxicillin 250 mg/5 mL
suspension. The second case
involved a 3-year-old boy who was
prescribed TAMIFLU (oseltamivir)
suspension.
WorthRepeating: Not the proper mix
Add a note or label to the prescription
receipt indicating that the product
needs to be mixed prior to dispensing.
Consider keeping the actual product
container that requires mixing in a
separate area. At the point-of-sale,
open the bag and review the label,
route of administration, storage
requirements, and directions for use
with the patient. Open the bottle with
the patient and/or caregiver.
03/13
Because females may experience
impairment of alertness in the
morning after taking zolpidem, FDA
has recommended doses for women
be lowered from 10 mg to 5 mg for
immediate-release and from 12.5 mg
to 6.25 mg for the extended-release
products. These lower doses should
be considered for men too.
Issue
Problem
AmbulatoryCare ActionAgenda
Action Required/ Assignment
Date Completed
Reduce zolpidem (AMBIEN) dose
When dispensing zolpidem products
ensure that the doses are appropriate
for the patient. Pharmacists should
screen orders for zolpidem to monitor
adherence to the new FDA dosing
recommendation.
Look-alike oxymorphone and methadone bottles
May 2013
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

ACAA 3
January – April 2013
ISMP
Issue
03/13
May 2013
Problem
After dispensing oxymorphone, the
pharmacy staff returned the stock
bottle to storage. However, the bottle
was placed back in among bottles of
methadone. Both products were from
the same manufacturer and the
bottles and container labels looked
similar. The next time methadone
was to be dispensed, the
oxymorphone bottle was actually
selected.
AmbulatoryCare ActionAgenda
Recommendation
Explore ordering one of the products
from a different manufacturer.
Discourage staff from relying solely on
visual cues on packaging when
stocking pharmacy shelves. Avoid
storing these medications next to one
another. When products are found
misplaced on the shelf, consider why,
discuss the potential for error, and
develop preventive measures.
Organization Assessment
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

Action Required/ Assignment
Date Completed
ACAA 4
January – April 2013
ISMP
Issue
Problem
01/13
A patient received oxyCODONE
instead of OXYCONTIN
(oxyCODONE extended release).
The technician and pharmacist
missed “OxyCONTIN” which was
printed immediately below
“oxyCODONE” on the electronic
prescription. The lack of the modifier
“extended release” likely contributed
to the technician and pharmacist
interpreting the prescription as
oxyCODONE instead of
OxyCONTIN.
03/13
A prescriber wished to enter an order
for acetaminophen by typing “aceta,”
but then accidentally choose
acetaZOLAMIDE from the search
results. Because the first portion of
the generic or brand names for
different medications are identical,
and when only a few letters of the
drug are entered into the search box,
the user is often presented with a
menu of choices and may quickly
choose the medications that appear
at the top of the list. Some other drug
name pairs that have led to this kind
of error are:
hydroxychloroquine/hydroxyurea;
MUCOMYST (acetylcysteine)/
MUCINEX (guaiFENesin);
valACYclovir/valGANciclovir; and
penicillAMINE/penicillin.
03/13
A home infusion company dispensed
84 vials of diphenhydrAMINE
injection rather than vials of
multivitamins (which the patient adds
May 2013
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Drug name fields on prescription
Electronic prescribing and electronic
health record vendors must ensure
their systems display appropriate drug
names in a clear and understandable
manner (e.g., OxyCONTIN
[oxyCODONE extended release]).
Prescribers should examine how
prescriptions appear on computer
screens and faxed, printed, or
electronically transmitted prescriptions
when they evaluate vendor systems.
Pharmacy staff should verify with the
patient at the point-of-sale what was
ordered and dispensed.
Action Required/ Assignment
Date Completed
Searching for medication names during order entry
Visually differentiate names. Require
typing as much of the drug name as
possible when searching, rather than
just a few letters. Double-checking the
choices that are in the order entry
browser, being familiar with the usual
dosing and frequency of the intended
drug, or checking references can also
help. Require entry of the intended
purpose of drugs with similar
indications or build an alert for the
pharmacist to verify that the indicated
use matches the patient’s condition.
Benadryl dispensed instead of vitamins for home parenteral nutrition
Require a documented, independent
double-check of all supplies against
the original patient’s orders before
delivery is made. Patients can also
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

ACAA 5
January – April 2013
ISMP
Issue
May 2013
Problem
at home to her parenteral nutrition
[PN] admixtures). The patient added
diphenhydrAMINE to the PN which
infused for 2 consecutive nights,
resulting in significant drowsiness.
The error was discovered when she
called the home infusion company
on the third day to inquire about the
different looking vials she was using.
AmbulatoryCare ActionAgenda
Recommendation
serve as a double-check by reviewing
their delivered supplies when they
arrive and again each night before
beginning the infusion. Verification of
the infusion against the current PN
order is optimal, but a copy of the
order must be requested from the
home infusion company and provided
to the patient for comparison.
Organization Assessment
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

Action Required/ Assignment
Date Completed
ACAA 6