October – December 2010
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 October-December 2010
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 description of the medication safety problem, 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 the ISMP List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). The Action Agenda is also available for download in
a Word format (www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1101.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:
Problem
No.
(20
)
Drug shortages take an
enormous toll on
healthcare providers who
must deal with the
problem on a daily
basis, and on patients
who are on the receiving
end of the shortages.
Although it may be
impractical to prepare
for every potential drug
shortage, proper
planning can minimize
the adverse effects on
patients and providers.
January 27, 2011
— ISMP high-alert medication
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Managing drug shortages
Identify a person/team to
identify drug shortages
by reviewing the ASHP and
FDA websites and
communicating with other
hospital purchasers. Once
a shortage has been
identified, assess
current inventory,
identify and approve
therapeutic alternatives,
tailor the drug’s use to
priority patients for
whom an alternative may
be unsafe, and conduct a
failure mode and effects
analysis to identify
process changes and
potential misuses of
alternative products.
Keep staff updated on
shortages and how they
will be addressed.
Infection control practices with needles, syringes, and vials needs stepped-up monitoring
ISMP MedicationSafetyAlert!

QAA 1
October – December 2010
ISMP
QuarterlyActionAgenda
Problem
Recommendation
(24
)
A recent online survey
of 5,446 nurses revealed
an alarming lapse in
basic infection control
practices, including:
reuse of a syringe for
another patient after
only changing the
needle, reuse of singleuse vials for multiple
patients, reentry into a
multiple-dose vial with
the same needle/syringe,
and use of a common bag
or bottle from which to
prepare IV flush
solutions or drug
dilutions. These
practices place patients
at risk for transmission
of blood borne diseases.
Enhance surveillance of
proper technique and
devote resources to
ensure staff knowledge
and skills associated
with concepts of
infection control and
injection safety. Use
prefilled syringes or
single-dose vials when
possible to reduce the
risk of contamination.
Inexpensive drugs should
be provided in single-use
containers and discarded
after first use. Do not
use bags or bottles of IV
solutions as a communal
supply of flushes for
multiple patients.
(21
)
All US clinical
laboratories are now
using a new standardized
IDMS method to measure
serum creatinine. The
IDMS method appears to
underestimate serum
creatinine values,
resulting in an
overestimation of the
glomerular filtration
rate (GFR) and the
potential for
CARBOplatin-related
dosing errors or
toxicity.
(21
Taxotere now comes in a
No.
January 27, 2011
Organization Assessment
Action Required/
Assignment
Date Completed
New Isotope Dilution Mass Spectrometry (IDMS) may affect CARBOplatin dosing
To avoid potential
toxicity, cap the dose of
CARBOplatin for desired
exposure (area under the
curve [AUC]) if a
patient’s GFR is
estimated based on serum
creatinine measurements
using the IDMS method.
Specific recommendations
appear on the FDA website
at:
www.fda.gov/AboutFDA/Cent
ers
Offices/CDER/ucm228974.ht
m.
New TAXOTERE (DOCEtaxel) concentration and preparation
Alert all pharmacy and
ISMP MedicationSafetyAlert!

QAA 2
October – December 2010
ISMP
QuarterlyActionAgenda
Problem
Recommendation
&
23)
new one-vial double
concentration
formulation, replacing
the previous two-vial
(active drug and
diluent) Taxotere
packaging. The new onevial concentration is 20
mg/mL compared to the
previous two-vial
preparation, which was
10 mg/mL. A forthcoming
one-vial generic
DOCEtaxel product
(Hospira) will be
provided in a 10 mg/mL
concentration, the same
as the previous Taxotere
formulation but
different than the new
formulation.
oncology nursing staff to
the new formulation in a
double concentration (20
mg/mL) and the
forthcoming generic
product that will be
available in the prior
concentration (10 mg/mL).
Update computer system
databases and internal
drug resources to ensure
proper mixing. If your
computer system allows
for order replication
from past admissions,
work with your IT
department to intercept
orders where medications
have changed strengths.
For additional
information, visit:
www.ismp.org/sc?k=taxoter
e.
(21
)
A woman admitted to a
hospital with burns on
her arm had orders for
topical wound irrigation
with Dakin’s solution.
An IV was started in the
same arm and later
capped but not removed
because it was partially
covered by the burn
dressing. The nurse
believed the capped IV
was an irrigation
catheter under the
dressing and
No.
January 27, 2011
Organization Assessment
Action Required/
Assignment
Date Completed
Accidental IV administration of Dakin’s (diluted sodium hypochlorite) solution
Apply clearly visible
labels on access lines
that are covered with
dressings or clothing.
Trace tubing and
catheters to the point of
origin to prevent
misconnections. Ask
vendors to supply a setup
for irrigations that
won’t connect to an IV
access port (e.g.,
Hospira sterile water for
irrigation bottle with a
screw cap and an
ISMP MedicationSafetyAlert!

QAA 3
October – December 2010
ISMP
Problem
No.
administered the Dakin’s
solution via the capped
IV catheter.
(20
)
(20
)
(23
&
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
irrigation administration
set). When possible,
prepare irrigations in
the pharmacy in
containers that are
dissimilar to IV
containers.
Confusion between Hospira’s HYDROmorphone and ePHEDrine
Consider purchasing one
of the products from a
different manufacturer.
Barcode scanning and
independent checks by at
least two pharmacy staff—
which led to error
detection in this case—
are also measures to
prevent mix-ups.
A pharmacist caught an
error in which Hospira’s
HYDROmorphone 4 mg
ampuls had been pulled
for unit stock instead
of the intended
ePHEDrine sulfate 50 mg
ampuls. The yellow and
white labels and cartons
for both products look
very similar.
Improving compliance with the use of smart infusion pump libraries
During a 3-year study on
Share the published
smart pumps, overall use
article with your
of safety software rose
continuous quality
from 33% in November
improvement (CQI) team,
2006 to over 98% by
pharmacy and therapeutics
December 2009 (Breland
committee, and hospital
BD. Continuous quality
administration if you are
improvement using
struggling to improve
intelligent infusion
compliance with the use
pump data analysis. Am J
of smart pump drug
Health-Syst Pharm. 2010;
libraries.
67:1446-1455). Many
clinically significant
dosing errors were
intercepted and
corrected by the safety
software.
ISMP updates list of look-alike drug names with recommended TALL man letters
Drug names that appear
Highlighting a unique
to be very similar when
portion of a drug name by
January 27, 2011
ISMP MedicationSafetyAlert!

QAA 4
October – December 2010
ISMP
QuarterlyActionAgenda
Problem
Recommendation
25)
handwritten and/or
typewritten (e.g.,
computer screens, typed
labels) have a high
potential of being
confused, leading to
drug prescribing,
dispensing, and
administration errors.
Difficulties with the
use of tall man letters,
which can help
distinguish look-alike
names, include
inconsistent application
in health settings and
lack of standardization
regarding which name
pairs to include as well
as which letters to
present in uppercase.
using “tall man”
lettering draws attention
to the dissimilarities of
look-alike drug names.
Following a recent
survey, ISMP updated its
list of drug name sets
with tall man letters
using a standard method
for selecting which
letters should be
capitalized. Use the tall
man lettering scheme
provided in this list
(www.ismp.org/tools/
tallmanletters.pdf) to
promote consistency.
(22
)
A nurse unfamiliar with
the new design of the
EpiPen accidentally
injected her thumb by
pushing on the wrong end
(orange tip) of the pen,
presuming that it was
similar to the NOVOLOG
(insulin aspart)
FLEXPEN, which has an
orange button to inject
the insulin. While
injecting EPINEPHrine
into a thumb or finger
may cause restricted
tissue perfusion, the
greater risk is to the
patient if EPINEPHrine
No.
January 27, 2011
Organization Assessment
Action Required/
Assignment
Date Completed
Thumb can still be injected despite EpiPen (Dey Pharma) redesign
Provide healthcare
professionals and
patients with
instructions on the
proper use of an EpiPen
(visit:
www.epipen.com/page/howto-use-epipen).
Incorporate a return
demonstration by the
healthcare professional
and/or patient to ensure
understanding of the
procedure and skill when
performing the required
injection.
ISMP MedicationSafetyAlert!

QAA 5
October – December 2010
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
administration is
delayed.
(22
)
(24
)
(21
)
CATAPRES-TTS (cloNIDine transdermal therapeutic system) adhesive cover applied without drug patch
Catapres-TTS is packaged
Have pharmacy dispense
with an optional white,
each patch/cover pair in
round adhesive cover to
a plastic bag with a
use over the patch in
label reminder to apply
case it comes loose.
the medication patch and
ISMP received several
adhesive cover. If
reports in which just
applying the white patch
the cover was applied to
cover over the tan
the patient without the
medication patch, label
patch containing
the cover before
cloNIDine. One patient
application with the drug
at a long-term care
name and strength, and
facility did not receive
leave a small edge of the
cloNIDine for 2 weeks
medication patch
because only the cover
uncovered to identify
was applied.
that the medication patch
is underneath.
Nasal calcitonin-salmon confused with injectable product
A physician prescribed
Never dispense the nasal
IM calcitonin-salmon,
formulation without
but the pharmacy
sending the accompanying
dispensed a vial of the
spray applicator. If
nasal formulation
possible, order FORTICAL
without the nasal
nasal spray rather than
applicator. A nurse
the generic product.
failed to recognize that
Fortical is manufactured
the incorrect
with a simple twist-off
formulation was
style cap, and the vial
dispensed and attempted
is less easily confused
to get an IM dose from
with the injectable
the vial by inserting a
formulation.
needle through the
stopper.
Confusing Sandoz itraconazole packaging
The itraconazole “100
To prevent confusion,
mg” capsule strip pack
label this product as
actually contains two
itraconazole 200 mg (2 x
100 mg capsules. Staff
100 mg capsules). If you
January 27, 2011
ISMP MedicationSafetyAlert!

QAA 6
October – December 2010
ISMP
QuarterlyActionAgenda
Problem
Recommendation
may believe that the two
capsules together equal
100 mg, which can lead
to dosing errors.
supply unit dose products
to nursing homes or other
outpatient settings, you
may want to note this on
the medication
administration record or
repackage the product.
No.
(23
,
25)
Serious burns may occur
in patients undergoing
MRI who are wearing
transdermal patches that
contain metal. The metal
acts as a conductor of
radiofrequency pulses,
inducing electric
current.
(20
)
When conventional time
(using a.m. and p.m.
designations) is used to
time orders and
medication entries,
confusion may arise
regarding whether
“midnight” means the
very end of the day or
January 27, 2011
Organization Assessment
Action Required/
Assignment
Date Completed
Metallic content of drug patches and magnetic resonance imaging (MRI)
Instruct all patients who
use transdermal patches
to notify staff when they
are about to undergo any
testing such as MRI.
Obtain the latest review
(http://thomasland.metapr
ess.com/content/lh6x4h1g6
8815272/?p=6a2ede3d480d4a
d3bbc5d4e1d095586b&pi=6)
on metal in drug patches,
which provides
information related to
the metallic content of
available transdermal
patches and the
recommendations regarding
reapplication of
transdermal therapy after
a scan.
Document using military not conventional time
ISMP suggests standard
utilization of military
time in hospital settings
for all documentation of
time to avoid any
potential confusion.
ISMP MedicationSafetyAlert!

QAA 7
October – December 2010
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
the very beginning of
the next day.
(25
)
A woman who had had
cataract surgery was
reaching for her eye
medications when she
mistook Super Glue for
eye ointment and glued
her eye shut.
January 27, 2011
SUPER GLUE (cyanoacrylate) mixed up with eye medications
In the event that eyelids
are stuck together or
bonded to the eyeball,
Super Glue Corporation
recommends that you wash
the area thoroughly with
warm water and apply a
gauze patch. The eye will
open without further
action within 1-4 days.
Individuals using
ophthalmics should be
warned not to purchase
Super Glue in a container
that looks like an eye
medication, and they
should store the glue far
away from all
medications.
ISMP MedicationSafetyAlert!

QAA 8