July – September 2012
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 July-September 2012 issues of theISMPMedication Safety Alert! havebeen prepared for an interdisciplinary committeetostimulatediscussion and action toreducetherisk of medication errors. Each item
includes adescription of themedication safety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional information as desired. Look for our high-alert medication icon under theissuenumber if theagendaitem
involves oneor moremedications on the ISMP’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). TheAction Agendais alsoavailablefor download in aWord format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1204.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:
No.
Problem
(15)
Due to a shortage of KCl injection
concentrate in vials and pharmacy bulk
packages, a technician purchased KCl
20 mEq syringes from an outsourcing
company. The syringes were left on a
counter after removing an overwrap
with a warning statement. A pharmacist
thought these were cefazolin syringes
because they had a similar red cap and
placed them in the refrigerator with
other cefazolin syringes. Fortunately,
she noticed her mistake.
(19)
Recommendation
—ISMP high-alert medication
Organization Assessment
Action Required/
Assignment
Date Completed
Potassium chloride (KCl) injection concentrate in a syringe
The company no longer provides
KCl syringes but other companies
may do so. KCl vials must have a
black cap and closure that states,
“Must be Diluted.” Unlike syringes
from which a drug can be directly
injected, vials signal that additional
steps are needed prior to injection.
ISMP urges hospitals to only
purchase KCl in vials, not syringes,
and to never remove caps or
overwraps with warning statements
until just prior to use.
Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections
Some staff have been using
The pharmacy should oversee the
pharmacy bulk packages (PBPs) of
purchase, dis-tribution, storage, and
contrast media inappropriately as
use of IV contrast media in all
multiple-dose containers for multiple
inpatient and outpatient clinical
patients in radiology, cardiac
areas. Staff should draw up doses
catheterization lab, and cardiac
of IV contrast media from singlesurgery locations. Staff may believe
dose vials or use prefilled singlethe PBP is a multiple-dose container
use syringes from the pharmacy or
because some manufacturers refer to manufacturers. The contents of
it as a “multipack” and some power
PBPs should only be transferred to
injector manufacturers suggest such
single-dose containers or syringes
use. PBPs of contrast do not contain
in the pharmacy under a laminar
preservatives to help prevent
flow hood or other USP <797>
contamination and the spread of
suitable environment within 4-10
infection.
hours of initial entry into the bag.
October 4, 2012
ISMP MedicationSafetyAlert!

QAA 1
July – September 2012
ISMP
No.
Problem
(14)
A community pharmacy dispensed
methadone to a child in a vial
labeled with the prescribed drug,
methylphenidate. The child required
hospitalization but recovered. The
mix-up has also happened in
hospitals. Both drugs have
overlapping tablet strengths (10 mg)
and may appear together on
computer selection screens.
(18)
An unresponsive patient was
brought to the hos-pital with
multiple fentaNYL patches on his
body. The patient followed the
directions to “apply one patch every
72 hours,” but was not told to
remove the older patch prior to
applying a new patch.
(15)
EpiPens are only available in a 2Pak containing two EpiPens and a
nonfunctioning training pen. The
training pen looks similar to the
actual Epi-Pen. An emergency
department’s automated dispensing cabinet was accidentally
stocked with an EpiPen training
device instead of the active pen.
(17)
Novartis sent a letter to hospitals
that highlighted the accidental
administration of methylergonovine
to newborns instead of the ordered
hepatitis B vaccine. Two of the
recent mix-ups involved generic
methylergonovine and Engerix-B,
October 4, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Mix-ups between methadone and methylphenidate
Configure mnemonics in order
entry systems to prevent
confusion between methadone
and other drugs that start with
“met” or “meth” and have similar
strengths. Separate
methylphenidate and methadone
in storage areas. Implement
barcode scanning in the pharmacy
to identify when the wrong product
has been selected from the shelf.
Teach patients to remove older transdermal fentaNYL patches
Ensure that patients who are
prescribed transdermal patches
understand proper use and
disposal. ISMP has developed a
safety checklist
(www.ismp.org/sc?id=90) that can
be used by those providing
education and given to the patient
afterwards for reference.
Confusion between EPIPEN (EPINEPHrine injection) training device and active pen
If hospitals store EpiPens on
clinical units or in code carts,
remove the pens from their carton
and only store the active pens in
unit stock. Be sure staff know
about the risk of confusion
between the training pens and
actual pens.
Generic methylergonovine maleate and ENGERIX-B (hepatitis B vaccine) mix-ups
Separate newborn medications
from those used for mothers. If
newborn and perinatal
medications must be stored
together in automated dispensing cabinets, use locked,
lidded medication bins for
ISMP MedicationSafetyAlert!

QAA 2
July – September 2012
ISMP
Problem
No.
which are packaged in vials that
look very similar.
(15)
A DOCEtaxel order was entered
into the pharmacy computer
system. The pharmacy technician
preparing the product discovered
that the DOCEtaxel concentration
in stock had changed. The
computer system did not have the
new concentration listed in its
inventory, so the drug amount on
the label in mL was incorrect.
(14)
An order for “fentaNYL transdermal
72h apply 1 patch 12 mcg/hour
externally q3d” was misunderstood
as 75 mcg/hour. The number 72
was mis-read as 75 and mistaken
as the mcg/hour dose.
(16)
A nurse flushed a post-op patient’s
IV line previously used by
anesthesia. The patient became
unresponsive because several mg
of rocuronium present in the tubing
was inadvertently flushed into the
patient. Depending on the drug
concentration, IV set volume, and
point of injection, unintended doses
of drugs are possible when flushing
lines or administering IV
medications.
October 4, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
pediatric products and highlight
whether medications are for the
mother or infant on the selection
screen. If possible, administer
infant medications in an area
separate from where medications
are administered to the mother.
Protocol needed for drug concentration change
When purchasing alternative
products or strengths that are
different than normally stocked, a
verification process is needed to
ensure that changes are made in
computer systems, includ-ing IV
compounders and robots,
automated dis-pensing cabinets,
computer order entry systems,
smart pumps, and other affected
technology.
Unnecessary drug release time (72h) within fentaNYL order misunderstood as dose
Advise prescribers to avoid listing
the patch release rate (72h) when
ordering fentaNYL patches.
Ensure that patients who receive
fentaNYL patches are not opioid
naïve.
Medication within IV tubing may be overlooked
Flush IV lines as proximal to the
patient access site as possible
after clamping the line
immediately above the point of
injection. For IV piggybacks, the
insertion point should be at a Ysite closest to the patient’s access
site. Post-procedure, anesthesia
should flush lines or change the
tubing, and remove any source
medication container, prior to
extubation.
ISMP MedicationSafetyAlert!

QAA 3
July – September 2012
ISMP
No.
Problem
(17)
Not all graduate nurses know that
oral syringes are available, their
purpose, or how to use them. One
nurse expelled an oral syringe of
LORazepam into a parenteral
syringe and administered it IV after
voicing frustration that the
pharmacy-dispensed syringe could
not be connected to the IV port.
Another nurse expelled oral
morphine solution into a dosing
cup, diluted it, drew it into a
parenteral syringe, and injected it
IV.
(19)
Several patients sustained severe
skin or mucosal burns after
undiluted glacial acetic acid
(99.5%) was dispensed and
applied instead of a 5% acetic acid
solution. The strength of the
solution was not readily visible on
the bottle label, and the pharmacist
believed glacial acetic acid was a
5% solution pre-diluted by the
manufacturer.
(10,
14)
Organizations sometimes provide
hasty affirmations that they are
operating within a Just Culture,
when direct observations belie
such affirmations. As a result, Just
Culture has simply become a
popular catch phrase for many,
without full understanding of its
tenets and nuances, and its critical
link to patient safety.
October 4, 2012
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Avoiding inadvertent IV injection of oral liquids
Include education on accidental
injection of oral liquids and the
purpose for using oral syringes
during nursing orientation and
new graduate mentorship. Ensure
that oral syringes are available in
all patient care units, and affix
auxiliary labels that state “ORAL”
to all medications dispensed in
oral syringes.
Remove glacial acetic acid from pharmacies
Remove glacial acetic acid from
the pharmacy and replace it with
vinegar (5% solution) or
commercially available diluted
acetic acid. Educate staff about
the differences between glacial
acetic acid and lesser
concentrations. Take precautions
if pharmacy dilution of acetic acid
must occur, including
development of a standard mixing
procedure and double-checks.
Just Culture and its critical link to patient safety (Part 1 and 2)
To assess how far along an
organization is on its journey to a
Just Culture, consider the selfassessment questions in ISMP’s
Just Culture newsletter series
(www.ismp.org/sc?id=100 and
www.ismp.org/sc?id=101), and
consider participating in the
Agency for Healthcare Research
and Quality Hospital Survey on
Patient Safety Culture
ISMP MedicationSafetyAlert!

QAA 4
July – September 2012
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
(www.ahrq.gov/qual/hospsurvey1
2/).
(15)
Intimidation in the workplace has
repeatedly surfaced as a significant
barrier to safety. A less obvious but
dangerous environment exists
when staff speak up about
concerns but are too easily
convinced that they are unfounded,
and when the person being
questioned has not perceived the
concern as a credible threat. A
natural deference to expertise can
lead to unintended complacency
and tolerance of risk that goes
unchallenged.
(16)
An ISMP survey of 540 nurses
using Carpuject prefilled syringes
found that 68% were unaware of
significant cartridge overfill that
could lead to overdoses. Nurses
also reported using the prefilled
cartridges as multiple-dose vials,
risking contamination and
unlabeled syringe contents. Factors
that encourage this practice include
unavailability of Carpuject syringe
holders, the need to dilute the
product, and preventing drug
waste.
(17)
Mylan’s lyophilized melphalan is
co-packaged with a diluent that is
not clearly labeled and has been
confused as the actual drug. The
vials of drug and diluent are the
October 4, 2012
Red flags that represent credible threats to patient safety
Raise the index of suspicion for
errors, always anticipating and
investigating the possibility when
anyone, regardless of experience
or position, voices a concern or
when patients are not responding
to treatment as anticipated. Staff
need to trust in their own
experiences to augment the
expertise of others, and to be
receptive to staff who ask
questions. Visit
www.ismp.org/sc?id=102 for a list
of skills to encourage appropriate
responses to concerns.
ISMP survey reveals user issues with CARPUJECT prefilled syringes
Do not use the Carpuject
cartridges as multiple-dose vials.
Drugs that require further dilution
should be prepared by pharmacy
when possible. If dilution is
required on the unit and a 1:1
ratio is acceptable, drawing a
small volume of a diluent from a
single-dose vial directly into a
cartridge (1 mL fill or less) may be
considered. Provide an adequate
supply of Carpuject syringe
holders.
Mylan’s melphalan diluent vial confused as actual drug vial
Add an auxiliary label to the
diluent to properly identify it, or,
until improved labeling by Mylan,
search for a different
manufacturer for this product.
ISMP MedicationSafetyAlert!

QAA 5
July – September 2012
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
same size, both have white caps
and similar label colors, and the
diluent label has the drug name
listed prominently.
(17)
A patient administered 46 units
instead of 6 units of insulin when
she misread the dose she had
dialed using a NovoLOG FlexPen
by reading the numbers to the right
of the dosing window, not within the
dosing window. Other pen issues
experienced by patients include
inserting the needle but not
pressing the button to release the
dose or turning the dial to release
the dose.
October 4, 2012
NOVOLOG FLEXPEN (insulin aspart) dose misread by patient
Patients who are prescribed an
insulin pen should meet with a
certified diabetes educator,
pharmacist, or nurse to
demonstrate proper dose
selection and use.
ISMP MedicationSafetyAlert!

QAA 6