July – September 2009
ISMP
QuarterlyActionAgenda
x
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. Topromotesuch aprocess,
thefollowing selected items fromtheJuly-September 2009 issues of theISMPMedication Safety Alert! havebeen prepared for an interdisciplinary committeetostimulatediscussion and action toreducetherisk of medication errors.
Each itemincludes adescription of themedication safety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional informationas desired. Look for our high-alert medication icon under theissue
number if theagendaiteminvolves oneor moremedications on the ISMPList of High-Alert Medications. TheAction Agendais alsoavailablefor downloadin aWord format (www.ismp.org/Newsletters/acutecare/articles/ActionAgenda0904.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 theISMPMedicationSafety
Alert! section of our websiteat: http://www.ismp.org. Continuing education credit isavailablefor nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp
.Key:
Problem
No.
(19)
The Anesthesia Patient Safety
Foundation (APSF) recently
published an editorial regarding the
continuing problem of opioidinduced respiratory depression.
APSF identified inadequate
monitoring of oxygenation and/or
ventilation, in addition to failure to
consider patient-specific
characteristics, as causes for the
continued occurrence of opioidinduced respiratory depression.
(19)
The auditory signal or beep issued
by certain hospital point-of-care barcoding systems to indicate that the
scanner successfully read a barcode
may be misinterpreted as a signal
that the correct patient and drug
have been selected, particularly if
the computer screen cannot be
viewed clearly.
April 23, 2009
—ISMP high-alert medication
Recommendation
Organization
Action Required/
Assessment
Assignment
APSF offers recommendations for safe post-op opioid administration and monitoring
Date Completed
According to APSF, the following
should be addressed in all patients
receiving postoperative opioids: 1)
Individualize each patient’s dose based
on the patient’s history and physical
status; 2) Make pulse oximetry routine;
3) Assess each patient’s need for
supplemental oxygen; and 4) Consider
capnography to monitor ventilation,
particularly for patients receiving
oxygen and/or at high risk for opioidinduced respiratory depression (e.g.,
depressed level of consciousness,
preexisting respiratory impairment,
sleep apnea, and very sick, elderly, or
obese patients).
What does a bar-coding scanner beep mean?
Evaluate your point-of-care barcoding system to identify if any
auditory signals could be
misunderstood. Educate staff
regarding the meaning of auditory
signals related to bar-coding systems.
For vendors of bar-coding systems,
consider using different auditory
signals to distinguish a correct drug
that is scanned from an incorrect
drug.
Insulin errors
ISMP MedicationSafetyAlert!

QAA 1
July – September 2009
ISMP
Problem
No.
(14)
(16)
(14,
15)
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
A renal transplant recipient
Develop a medication preparation
developed cardiopulmonary
course and preceptor program for
instability after receiving 100 units
new residents and anesthesia, OR,
instead of 10 units of regular insulin
PACU, and pharmacy staff. In
IV for the treatment of hyperkalemia. hospitals with OR pharmacy satellites,
An anesthesiology resident drew 1
insulin dilution and dose preparation
mL of U-100 insulin into a 10 mL
should occur in the satellite
syringe, added 9 mL of saline, and
pharmacy, or an insulin minibag
injected the entire contents.
system (prediluted to 1 unit/ mL) may
Inadequate hospital orientation and
be used (however, insulin adherence
training of residents in medication
to plastic IV bags/tubing makes it
preparation was a key contributing
difficult to estimate exactly how much
factor.
insulin is reaching the patient).
Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children
Two 6-year-old children died from
Administration of hypotonic saline or
severe postoperative hyponatremia. parenteral fluids without saline is
In the first case, the rapid
physiologically unsound and
administration of plain D5W
potentially dangerous for hospitalized
(dextrose 5% in water)
children. Thus, standards of practice
postoperatively resulted in free
should be established for
water retention (also called water
postoperative IV solutions used to
intoxication). In the second case, the hydrate patients–particularly children.
child received several doses of
Protocols should be established to
furosemide and EDECRIN
identify, treat, and monitor patients
(ethacrynic acid), exacerbating the
with hyponatremia, water intoxication,
loss of sodium. In both cases, staff
and/or SIADH. Consider establishing
failed to recognize the signs of
an interdisciplinary rapid-response
hyponatremia. Children who receive team that allows healthcare workers
hypotonic solutions are particularly
(or patients/families) to summon a
vulnerable to water intoxication
clinical team to the bedside for a full
because they are prone to
evaluation when they fear something
developing syndrome of
is wrong and have expressed their
inappropriate antidiuretic hormone
concerns without adequate response.
(SIADH), or the excessive release of
ADH.
Safety issues with elastomeric pain relief balls (ON-Q PainBuster and others)
Safety issues have been identified
Establish standard order sets for
with the ON-Q PainBuster, an
prescribing the pump and specific
elastomeric pump used after surgery medications. Allow use of local
to provide pain relief. The pump is
anesthetics only. The Joint
October 10, 2009
ISMP MedicationSafetyAlert!

QAA 2
July – September 2009
ISMP
QuarterlyActionAgenda
Problem
Recommendation
usually filled and started in the OR
without pharmacy involvement or
knowledge. Patients have appeared
on units where nurses have never
seen the pump. The pain ball has
been found unlabeled. Infusion rates
may vary due to over- or under-filling
of the balls; we’ve received one
report of premature emptying of the
pump. We have also received
reports of using the pump to deliver
medications other than local
anesthetics, including vancomycin,
fentaNYL, and morphine.
Commission defines parenteral
solutions in ON-Q pumps as IV
admixtures, which should be prepared
in the pharmacy except in urgent
situations. The pharmacy should use
a protocol that specifies the exact
amount of solution to instill in the
reservoir based on the duration of
therapy. Always label the pump (drug,
concentration, infusion rate, start
date). Other safety strategies can be
found at
www.ismp.org/Newsletters/acutecare/
articles/20090716.asp).
No.
(19)
FDA announced that it will be
requiring stronger manufacturer
warnings regarding severe tissue
damage associated with accidental
intraarterial administration or
extravasation of IV prometh-azine.
(17)
A vial of generic sulfamethoxazole
and trimethoprim injection was
accidentally placed in a bin for EPINEPHrine injection. A technician
took this vial from the EPINEPHrine
bin and scanned the label on the
bin, not the vial itself. The vial was
placed in a ziplock bag with a
October 10, 2009
Organization
Assessment
Action Required/
Assignment
Date Completed
IV promethazine update
If possible, remove promethazine from
the formulary and use alternatives such
as 5-HT3 antagonists (e.g., ondansetron)
when appropriate. If you MUST keep it
on the formulary, administer the drug by
deep IM injection only. Avoid IV use.
Additional FDA recommendations can
be found at:
www.fda.gov/Drugs/DrugSafety/Post
marketDrugSafetyInformationforPatie
ntsandProviders/DrugSafetyInformati
onforHeathcareProfessionals/ucm182
169.htm.
Scan product, not storage container label
To prevent mix-ups of products, scan
the product label itself when removing
drugs from bins, ADCs, or carousels.
The drug storage bin labels should
never be used to identify products.
ISMP MedicationSafetyAlert!

QAA 3
July – September 2009
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
barcode label. A pharmacist
checked the item by scanning the
barcode on the ziplock bag, not the
vial. A technician then placed the
item in an ADC, again scanning only
the ziplock bag.
(17)
(15)
(16,
17)
Name mix-ups between VALTREX (valacyclovir) and VALCYTE (valganciclovir)
Consider adding these drugs to your
list of look-alike drug names, and take
steps to reduce the risk of confusion,
including: building software alerts to
warn about possible confusion,
requiring staff to match the prescribed
drug with the patient’s medical
history, using both the brand and
generic names when prescribing or
listing these drugs, requiring readback of all oral orders, and using tall
man letters—valACYclovir and
valGANCIclovir—when listing the
drugs in computerized inventories.
Name mix-ups between PROVERA (medroxyPROGESTERone), PROZAC (FLUoxetine), and PROSCAR (finasteride)
A pharmacist misread a handwritten Consider adding these drugs to your
order for Provera 10 mg PO daily
list of look-alike drug names, and take
and dispensed Prozac 10 mg, which steps to reduce the risk of confusion,
the patient received until the next
including: building software alerts to
day. The handwritten order was
warn about possible confusion,
shown to several nurses,
requiring prescribers to include the
pharmacists, and physicians; one
drug’s purpose on orders, and
person thought the order was for
requiring staff to match the prescribed
Proscar.
drug with the patient’s medical
history.
Name mix-ups between KAPIDEX (dexlansoprazole) and CASODEX (bicalutamide)
There have been numerous reports
Consider adding Kapidex and
of errors due to name confusion
Casodex to your list of look-alike drug
between Kapidex and Casodex with names, and take steps to reduce the
both handwritten and oral
risk of confusion, including: building
prescriptions. ISMP also learned
software alerts to warn about possible
there is a foreign acetaminophen
confusion, requiring staff to match the
ISMP continues to receive reports
of mix-ups between Valtrex and
Valcyte. The generic names for
these two drugs are also strikingly
similar, and both the brand and
generic names of the products start
with the prefix “val.” Both have uses
associated with cytomegalovirus
(CMV) and may be used in
immunosuppressed patients with
human immunodeficiency virus
(HIV) or transplant patients.
October 10, 2009
ISMP MedicationSafetyAlert!

QAA 4
July – September 2009
ISMP
QuarterlyActionAgenda
Problem
Recommendation
and propoxyphene containing
product called Capadex available in
Australia, New Zealand, and online.
prescribed drug with the patient’s
medical history, requiring prescribers
to include the drug’s purpose on
prescriptions, and requiring read-back
of all oral orders.
No.
(18)
A physician ordered QUALAQUIN
(quinine sulfate) 324 mg for leg
cramps for a newly admitted patient.
The pharmacist selected a 324 mg
tablet from a list of products on the
computer screen. However, he
selected quinidine extended release
324 mg instead of quinine. This error
continued for 2 weeks. Fortunately
the patient was not adversely
affected. Mix-ups between quinidine
and quinine are common.
(16)
Pentacel is a 2-vial vaccine product that
requires mixing of the two components
before administration. Only the
DTaP/IPV vial carries the brand name
Pentacel. Clinicians may think only the
vial labeled Pentacel is needed. ISMP
has contacted the vaccine manufacturer
to suggest labeling changes.
(17)
Ohio pharmacist Eric Cropp was
sentenced to 6 months in prison, 6
months of home confinement, and
other criminal penalties for making a
human error that caused the death
of a child. During an independent
check, Eric failed to detect that a
pharmacy technician had used too
much 23.4% rather than 0.9%
Organization
Assessment
Action Required/
Assignment
Date Completed
Quinine-quinidine mix-ups still happen
The only approved indication for
quinine is to treat uncomplicated
Plasmodium falciparum malaria,
(rarely encountered in the US).
Quinine should not be available for
leg cramps and should be removed
from the formulary. If malaria is
encountered, access the drug from an
outside source. Use tall man letters
for quiNIDine and stock it only in the
available 300 mg strength (extended
release and immediate release).
PENTACEL (diphtheria and tetanus toxoids, acellular pertussis [DTaP], inactivated poliovirus [IPV], and Haemophilus b [Hib] conjugate)
October 10, 2009
Educate staff who will be
administering vaccines to children
about the need to mix the two vials. If
feasible, have pharmacy add auxiliary
labeling to the product before
dispensing it. Require documentation
of the NDC number, lot number, and
expiration date for each component in
the vaccine log.
Ohio government sentences pharmacist to jail time
Review your procedures for checking
pharmacy-prepared infusions of highalert medications to ensure that the
process is reliable. Ensure that
technicians preparing IV infusions are
well trained regarding the types of
products being used and the
appropriate use of 23.4% sodium
chloride. Whenever possible, use
ISMP MedicationSafetyAlert!

QAA 5
July – September 2009
ISMP
Problem
No.
sodium chloride as a diluent when
preparing a chemotherapy infusion.
Human factor research shows that,
under moderate stress, we fail to
detect an error about 20% of the
time.
(19)
A recent article suggests that onceweekly levothyroxine may be as
effective as daily dosing. This new
dosing regimen may lead to errors in
which the weekly dose is taken
daily. Errors may be difficult to
detect since daily administration is
the norm, doses vary between
patients, and a weekly dose may be
the same as a daily dose for some
patients.
October 10, 2009
QuarterlyActionAgenda
Recommendation
Organization
Assessment
Action Required/
Assignment
Date Completed
standard, premixed base solutions
(such as 0.9% sodium chloride)
instead of preparing base solutions by
hand. Restrict access to hypertonic
sodium chloride vials. Educate staff
about human factors and a Just
Culture.
Caution regarding once-weekly levothyroxine
Provide education to physicians
regarding the potential for error with
this weekly dosing regimen. Patient
education should include emphasis of
the weekly dosing schedule and the
potential for a dosing error.
ISMP MedicationSafetyAlert!

QAA 6