Download ISMP Medication Safety Alert - Institute For Safe Medication Practices

January – March 2009
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 January-March 2009 ISMP Medication 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 the
agendaiteminvolves oneor moremedications on theISMPList of High-Alert Medications. TheAction Agendais alsoavailablefor download in aWord format (www.ismp.org/Newsletters/acutecare/articles/ActionAgenda0902.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 alsobevisualized 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:
Problem
No.
(1)
Mead Johnson Nutritionals did little
to inform the public or healthcare
providers about changing the FerIn-Sol concentration from 15 mg of
iron/0.6 mL (25 mg/mL) to 15 mg
of iron/mL. The old and new
packages are identical except for a
brief note about the new
concentration on the new product
carton. Iron drops from other
manufacturers still use the 15 mg
of iron per 0.6 mL concentration.
(3,6)
An Army hospital announced that
2,114 insulin-dependent diabetic
patients may be at risk for
developing a bloodborne disease
because insulin pens were reused
for multiple patients. Although a
new needle was placed on the
pens before each use, crosscontamination is still possible. FDA
followed with an alert reinforcing
that sharing insulin pens may
result in transmission of
bloodborne diseases.
(5)
An opioid-naïve patient with
sleep apnea was started on
HYDROmorphone PCA with a
April 23, 2009
Recommendation
—ISMP high-alert medication
Organization Assessment
Action Required/
Assignment
Date Completed
Acutecare New Agenda Hed
Stock a standard concentration of
iron drops, and be sure the
formulary and drug indexes list
the correct concentration. Require
all orders to be written in mg,
never by volume alone. Always
verify the concentration of iron in
the product being dispensed and
administered as well as the
volume needed to provide the
intended dose.
Reuse of insulin pen for multiple patients risks transmission of bloodborne diseases
Facilities using insulin pens
should act immediately and
provide education and continuous
monitoring to prohibit situations
where an individual patient’s pen
might be reused for another
patient. Labeling each dispensed
pen with the patient’s name may
help reinforce that the pen is
intended for that patient alone. If
institutional safety with pen
devices can’t be assured, they
shouldn’t be used.
Beware of basal opioid infusions with PCA therapy
Establish risk factors and
screening criteria for basal
infusions and avoid their use for
ISMP MedicationSafetyAlert!

QAA 1
January – March 2009
ISMP
QuarterlyActionAgenda
Problem
Recommendation
basal infusion. She experienced
respiratory depression and
became unresponsive. The PCA
order form prompted for a basal
infusion without screening for
appropriate candidates. The
American Pain Society cautions
against using continuous basal
infusions because studies have
failed to demonstrate significant
differences in the quality of
analgesia with or without basal
infusions.
patients with sleep apnea and
patients who are not opioidtolerant (patients who have
received opioids regularly for 7 or
more days). Establish special
monitoring requirements (e.g.,
pulse oximetry/capnography,
frequent assessment in the first
24 hours and at night) for any
patient who receives a basal
infusion.
No.
(6)
A patient died after receiving an
injection of EPINEPHrine 1:1,000
from an unlabeled syringe that a
surgical nurse and surgeon
thought contained a local
anesthetic. EPINEPHrine for
topical use was on back-order, so
the nurse withdrew the contents
of a vial of the injectable product
into a syringe. The syringe was
mistaken as the local anesthetic.
(6)
Before hospital admission, a
patient with rheumatoid arthritis
had been taking oral
methotrexate 10 mg BID once
weekly on Mondays. On the
discharge medication list, the
drug was erroneously transcribed
as “methotrexate 10 mg po BID.”
The patient took the drug daily
using her current prescription
supply at home and had to be
readmitted for treatment of
April 23, 2009
Organization Assessment
Action Required/
Assignment
Date Completed
Fatal outcome after inadvertent injection of topical
Supply EPINEPHrine for topical
use only in the manufacturer’s or
pharmacy-prepared pour-bottles.
Never withdraw a topical product
into a parenteral syringe. Use
auxiliary labels to draw attention
to “TOPICAL” use only. Keep
local anesthetics for injection in
their original vials until ready to
use. Label all syringes. Use
presoaked EPINEPHrine pledgets
when feasible.
Methotrexate overdose
Before discharging patients,
medications on the discharge list
should be reconciled with the list
provided upon admission, and
discrepancies should be resolved.
Patient education should
emphasize the weekly dosing
schedule and, to ensure
understanding, patients
discharged on methotrexate
should receive follow-up phone
calls a day or two after discharge.
ISMP MedicationSafetyAlert!

QAA 2
January – March 2009
ISMP
Problem
No.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
serious side effects.
ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)
(3)
As with any technology, there are
benefits and risks associated with
ADC use. In 2007-2008, ISMP
convened a national forum of
stakeholders to develop
interdisciplinary guidelines for
promoting safe practices when
employing ADC technology.
Some factors that influence ADC
safety include: interconnectivity
with the pharmacy computer;
pharmacist review of orders
before removing drugs; use of
overrides; screen display of
patient and drug information; and
quantity of stock.
(1)
The total content in 4 mL vials of
heparin (10,000 units/mL) may
be mistaken as 10,000 units, not
40,000 units. The total volume is
easily missed on the label. Errors
could result in a serious
overdose.
(5)
Shortly after the release of
findings from a study that used
topical lidocaine to reduce
discomfort during breast
mammography, FDA issued an
advisory to remind patients,
healthcare professionals, and
caregivers about potentially
serious hazards—including
death—associated with overuse
of topical anesthetics.
April 23, 2009
If your organization uses ADCs,
form an interdisciplinary team to
review the guidelines
(www.ismp.org/Tools/guidelines/A
DC_Guidelines_Final.pdf), listen
to a recent webcast about ADC
safety
(www.cardinalhealth.com/clinical
center/materials/webcasts/index.a
sp), and complete a new ADC
self-assessment that will soon be
available on the ISMP website
(www.ismp.org).
Are 40,000 unit vials of heparin really needed?
Evaluate if your facility needs
heparin vials that contains 40,000
units. When possible, stock only a
1 mL vial of heparin 10,000
units/mL.
Topical lidocaine gel and mammography
Warn staff and consumers to use
topical anesthetics that contain
the lowest possible amount of
medication to relieve pain, apply it
sparingly on unbroken, nonirritated skin, and avoid wrapping
or covering the skin with any
occlusive dressing or other
material.
ISMP MedicationSafetyAlert!

QAA 3
January – March 2009
ISMP
Problem
No.
(4)
When someone fails to see what
should have been plainly
visible—a warning sticker on a
medication label, for example—
the cause is usually rooted in
inattention blindness, a condition
all people exhibit periodically. To
combat information overload, the
brain scans and sweeps until
something sticks out to capture
its attention. Unfortunately, the
brain is a master at filling in gaps
and making do, compiling a
cohesive portrait of reality based
on just a flickering view.
(4)
Valproic acid is available in
various dosage forms and salts,
so products can be confused. For
example, a patient was supposed
to receive DEPAKOTE ER
(ordered as “divalproex ER”) but
received divalproex “EC” (the
enteric-coated form of
divalproex). Another product,
DEPAKENE, contains valproic
acid when it is in capsule form
and valproate sodium in liquid
form. Valproate sodium is known
as DEPACON in parenteral form.
(5)
FDA issued a public health
advisory in March regarding
transdermal patches worn during
an MRI. Some patches are
formulated with an aluminized
backing or invisible metal layer
April 23, 2009
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
Inattentional blindness: What captures our attention?
To combat inattentional
blindness: 1) increase the
conspicuity of critical information
on product labels, computer
screens, medication
administration records, and other
sources of information, by using a
high degree of contrast with the
background; 2) ensure that the
critical information you are
providing is perceived as relevant
by those who need it; 3) decrease
multi-tasking and diversion of
attention when carrying out
complex tasks; and 4) reduce
over-reliance on technology.
Confusing nomenclature with valproic acid
Limit the forms of valproic acid
available in the hospital, and
educate staff about the different
dosing schedules and indications
for all formulations that remain. If
possible, add a computerized
alert to remind staff about the
potential for mix-ups. When
repeating back oral orders, use
full words (e.g., extended
release), not abbreviations.
Separate storage and use
auxiliary warning labels to
differentiate the products.
Patch advisory associated with safety during MRIs
Hospitalized patients being
discharged on a transdermal
medication should be educated to
remove the patch temporarily
when undergoing an MRI.
Facilities should follow published
ISMP MedicationSafetyAlert!

QAA 4
January – March 2009
ISMP
Problem
No.
that could cause excessive
heating and tissue damage to the
patient if worn during an MRI.
(1)
A pharmacist was consulted to
visit a patient for CUBICIN
(DAPTOmycin) dosing. The
pharmacist noticed that the
patient’s weight had been
entered into the computer as 150
kg instead of 150 lbs, which
equals 68 kg. The person
entering the weight failed to
convert lbs to kg after weighing
the patient on a scale that
measured weight in lbs.
(2)
An emergency department
patient with chest pain told the
doctor she was taking Revatio for
primary pulmonary arterial
hypertension. The physician did
not know Revatio was sildenafil,
the same drug as Viagra, so he
treated her with nitroglycerin
(sublingual and IV), which is
contraindicated.
(2)
A patient was admitted to a
hospital with an order for
Lopressor 100 mg BID. However,
the physician’s handwriting was
poor, and the order was
misinterpreted and dispensed as
Lyrica 100 mg BID.
(3,5)
Bausch and Lomb’s atropine
sulfate 1% and cyclopentolate
April 23, 2009
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
recommendations concerning
patients who wear patches and
undergo MRIs (www.imrser.org).
Lbs/kg confusion
Weights should always be based
on the metric system, and scales
should always weigh in kilograms.
It’s important that all preprinted
order sets, protocols, guidelines,
and computer screens only
prompt for kg weights.
REVATIO and VIAGRA are both sildenafil
Health professionals can reduce
the risk of errors by reviewing
readily accessible drug
information if they encounter
unfamiliar products. Also
encourage patients who take
Revatio to note on their
medication list that the drug is
also marketed as Viagra.
LYRICA (pregabalin) and LOPRESSOR (metoprolol tartrate) mix-up
Hospitals may want to add a
computer alert about this newly
reported look-alike drug name
pair. Matching the drug’s
indication to the patient’s health
condition is the best way to avoid
mix-ups between products with
look-alike names.
Color-coded eye medications
Avoid awarding contracts to one
vendor for an entire ophthalmic
ISMP MedicationSafetyAlert!

QAA 5
January – March 2009
ISMP
Problem
No.
1% ophthalmic drops look nearly
identical, which led to an error.
Another mix-up occurred
between polymyxin B and
trimethoprim ophthalmic solution,
and neomycin, polymyxin B, and
gramicidin solution. Packaging
similarities are related to colorcoding by pharmacologic class,
making all products within a class
the same color.
(4)
A pharmacist questioned whether
an order for magnesium chloride
64 mg TID “2Day” meant to give
the drug TID for 2 days or to give
it “today” (2Day). It turned out
“2Day” was “text messaging”
shorthand for “today.”
April 23, 2009
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
product line, and purchase
products within a class from
different manufacturers.
“2day” gets “86’d”
Text messaging language is not
appropriate for writing or
transcribing medical orders due to
potential misinterpretation.
ISMP MedicationSafetyAlert!

QAA 6