May-August 2014
ISMP
AmbulatoryCare ActionAgenda
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 agendaitems havebeen prepared for you and your staff tostimulatediscussion and collaborativeaction toreducetherisk of medication errors. Theseagendatopics appeared in the ISMPMedication Safety Alert!
Community/Ambulatory CareEdition between May 2014 and August 2014. Each itemincludes abrief description of themedication safety problem, recommendations toreduce therisk of errors, and theissuetolocateadditional information. TheAction
Agendais alsoavailablefor download in aWord format at: www.ismp.org/Newsletters/ambulatory/actionagenda.asp. Tolearn howtousetheISMPAmbulatory Care Action Agendaat your practicesite, visit
www.ismp.org/newsletters/ambulatory/How_To_Use_AA.asp.
Key:
Problem
Issue
07/14
Although oral chemotherapy is
associated with ease of
administration, an error with an
oral agent can be just as deadly
as an error with a parenteral
formulation of chemotherapy.
Ruth Ann Collins died as a result
of taking the equivalent of 3
cycles of oral lomustine therapy
at one time (450 mg), believing
the pharmacy had dispensed just
a single dose (150 mg). The
primary cause of the error that
accelerated Ruth’s death was the
dispensing of 3 doses of
lomustine rather than a single
dose.
07/13,
11/13,
05/14
Disrespectful behaviors in
healthcare persist unchecked and
are found at all levels of the
organization and among all
disciplines. According to ISMP’s
2013 survey, practitioners
frequently encounter
disrespectful behaviors that are
clearly learned, tolerated, and
reinforced in a culture that
considers a certain degree of
September 2014
Recommendation
—ISMP high-alert medication
Organization Assessment
Action Required/ Assignment
Date Completed
With oral chemotherapy, we simply must do better!
Prescribers should specify on the
prescription to dispense only a
single dose at a time. Program
warning messages such as
“single dose only” into order entry
systems. Pharmacists should
dispense a single dose and
combine strengths into a single
prescription vial if allowed by
state regulations. When possible,
enhance the presentation of the
dosing frequency direction and
warning on pharmacy labels
(e.g., CAUTION: TAKE A
SINGLE DOSE ONLY ONCE
EVERY 6 WEEKS). Prescribers
and pharmacists should provide
clear and detailed instructions to
patients. Nurses should reinforce
the importance of only taking a
single dose.
Disrespectful Behavior
Establish a committee and
educate members about the
causes and impact of
disrespectful behaviors.
Encourage reporting of
disrespectful behaviors and
establish a “no retribution” policy
for reporters. Create a code of
conduct or professionalism that
serves as a model of
interdisciplinary collegial
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 1
May-August 2014
ISMP
Problem
Issue
06/14
08/14
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/ Assignment
Date Completed
disrespect to be a “normal” style
relationships and collaboration.
of interaction. Productivity
Establish a communication
demands, cost containment, and
strategy for staff who must
hierarchies that nurture a sense
convey important information to
of status and autonomy have
enhance approachability and
been the most influential factors.
reduce intimidating behaviors.
Disrespectful behaviors cause
Establish an escalation policy to
the recipient to experience fear,
manage conflicts about the safety
vulnerability, anger, humiliation,
of an order when the standard
uncertainty, and self-doubt. The
communication process fails.
behaviors erode professional
Develop an intervention policy
communication and collaboration, that has leadership support to
and have been linked to adverse
consistently address disrespectful
events, even patient mortality.
behaviors.
ISMP Canada identifies themes associated with fatal medication events in the home
Analysis of fatal medication
The themes identified in the
events in the home identified
analysis underscore the need to
three categories of knowledge
educate patients about the
deficits: 1) unrecognized risks
medications they take at home,
associated with taking extra
particularly on these topics:
doses, sharing medications, and
importance of following
unsecured storage; 2)
instructions for use; seeking help
unrecognized signs of toxicity,
if the directions for use are
including unconsciousness
unclear; signs of toxicity,
mistaken as sleep, unreported
worsening symptoms, or sudden
changes in behavior, and a
changes in behavior requiring
reluctance to seek help; and 3)
intervention; and specific
lack of knowledge about specific
safeguards for the particular
drugs including opioids,
medication that is being taken.
psychotherapeutic drugs,
insulins, cardiovascular drugs,
anticoagulants, and
anticonvulsants.
ISMP has been reporting on this
mix-up since November 2008. In
one of the latest cases, a
prescriber electronically
prescribed rOPINIRole 0.5 mg for
a patient. When the prescription
arrived at the pharmacy, the
technician typed the medication
September 2014
WorthRepeating…RisperiDONE and rOPINIRole mix-ups
When prescribing either drug, the
drug name should be
electronically generated or
printed and the purpose of the
drug should be included on the
prescription. If the purpose of the
medication is not provided, the
pharmacist should contact the
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 2
May-August 2014
ISMP
AmbulatoryCare ActionAgenda
Problem
Recommendation
risperiDONE 0.5 mg which was
verified by the pharmacist. When
the patient picked up the
medication, she noticed the name
was different but thought that was
an alternate name for
rOPINIRole. She took a total of 5
tablets, reported having difficulty
sleeping and experiencing
involuntary movements in her
extremities.
prescriber to obtain it. In
pharmacies, do not store these
products near one another. Use
tall man letters for storage
labeling and computer listings.
Implementing barcode scanning
can identify when the wrong
product is selected from the shelf.
Assign time to provide counseling
to patients and/or caregivers,
especially for new prescriptions
and those transferred from other
pharmacies.
Issue
08/14
Mix-ups between
HYDROcodone-acetaminophen
and oxyCODONEacetaminophen combination
products have been occurring. In
the majority of reports, an
oxyCODONE-acetaminophen
product was dispensed instead of
the prescribed HYDROcodoneacetaminophen. Recent
reductions in the amount of
acetaminophen contained in
these products and overlapping
dosage strengths may be
contributing to the errors.
06/14
When electronically prescribing
Brintellix 10 mg daily for a patient
with major depressive disorder, a
physician incorrectly selected
Brilinta, an antiplatelet agent. The
patient picked up the filled
prescription but realized, after
reading an attached drug
information leaflet, that a mistake
had been made.
Organization Assessment
Action Required/ Assignment
Date Completed
HYDROcodone or oxyCODONE with acetaminophen?
Examine where these products
are stored. Close proximity and
similar looking containers can
increase the risk of mix-ups.
Prescribers should indicate on
the prescription how much
HYDROcodone or oxyCODONE
as well as acetaminophen is
intended. If the combination
prescribed isn’t available, the
pharmacist should contact the
prescriber. At the point-of-sale,
pharmacy staff should review
each prescription container with
the patient.
BRINTELLIX (vortioxetine) and BRILINTA (ticagrelor) drug name confusion
Consider building alerts to warn
about possible confusion.
Remind prescribers to use
generic names (in addition to
brand names) and list the
indication when prescribing these
drugs.
In medicine be wary of misspeakers who “shoot from the hip”
September 2014
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 3
May-August 2014
ISMP
Problem
Issue
08/14
A patient was prescribed
amoxicillin following some dental
work. However, she was allergic
to penicillin. After encountering
several instances of
“misspeaking” by healthcare
workers who said it was safe to
take, the patient took the
amoxicillin. Several days later
she developed a rash that
extended over her entire body.
Healthcare workers are often
pressured to give an answer
instantly and may “shoot from the
hip” and “misspeak.” Serious
errors are possible when
imprecision and misinformation
are introduced into patient care.
08/14
Packages of SUDAFED 12
HOUR (pseudoephedrine) and
SUDAFED 12 HOUR
PRESSURE + PAIN (naproxen
sodium and pseudoephedrine)
look-alike. Patients who fail to
recognize the difference between
these products could be at risk
for adverse effects.
07/14
Educating patients about safe
medication practices can be a
daunting task. Because patients
often seek information about
health and safety online,
pharmacies and other healthcare
organizations can help patients
reduce the risk of a medication
error by guiding patients to
reputable online resources.
September 2014
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/ Assignment
Date Completed
Build a culture in which all staff
feel safe and supported when
acknowledging that they don’t
know the answer to a question.
Provide training that helps staff
calibrate their assessment of
whether they should answer a
question, seek out the answer
and then provide it, or defer to
expertise. Enhance awareness
among management about the
impact their management style
may have on staff’s behavior.
Encourage patients to take an
active role in their healthcare.
Look-alike Sudafed products
Separate the products in storage
areas. Use shelf-talkers to direct
staff to the location of each
product. Consider placing alerts
on the products to bring attention
to the ingredients.
Guide patients to visit ConsumerMedSafety.org
Pharmacies, clinics, and
physician practices with a
website accessible to patients
should link to ISMP’s
ConsumerMedSafety.org, a
user-friendly, online resource that
imparts knowledge about safe
medication practices in ways that
consumers can easily access and
use. The real-world content can
be searched by topic or drug.
Stories, over-the-counter
medicine and insulin safety
sections, a medication safety
toolbox, and a consumer
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 4
May-August 2014
ISMP
Issue
Problem
AmbulatoryCare ActionAgenda
Recommendation
Organization Assessment
Action Required/ Assignment
Date Completed
medication error-reporting system
are examples of the content
areas.
September 2014
ISMP MedicationSafetyAlert!
Community/Ambulatory Care Edition

QAA 5