Download ISMP Medication Safety Alert - Institute For Safe Medication Practices

October – December 2012
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 2012 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’s List of High-Alert Medications (www.ismp.org/Tools/highalertmedications.pdf). The Action Agenda is also available for download in a Microsoft Word format
(www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1301.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:
No.
Problem
(23)
In an emergency department, a
pharmacist found a carton of
NovoLOG insulin in a refrigerator
bin where Nimbex cartons were
stored. Both have very similarlooking packaging. A mix-up either
way could be fatal.
(24)
On a medication reconciliation
form, the U-100 strength for
LANTUS (insulin glargine) was
listed instead of the dose under
the “dosage” section. This could
be mistaken as an insulin dose of
100 units.
(24,
25)
The US Food and Drug Administration
(FDA) announced that, effective May 1,
2013, heparin vial labels must express
the strength per the entire container
followed by the strength per mL in
parentheses (50,000 units/10 mL). In
the past, the strength was labeled only
January 24, 2013
Recommendation
—ISMPhigh-alert medication
Organization Assessment
Action Required/
Assignment
Potential mix-up between NOVOLOG (insulin aspart) and NIMBEX (cisatracurium)
Date Completed
In the pharmacy and clinical areas
where neuromuscular blockers are
necessary, segregate their storage in
a sealed container, lidded bin, or
intubation kit. Affix a warning label
stating: Warning: Paralyzing
Agent—Causes Respiratory
Arrest. When the drug is no longer
needed, place any leftover vials,
bags, and syringes of these drugs in
a sequestered bin for immediate
pharmacy removal.
Insulin concentration rarely needed on orders
Do not include the U-100
concentration with typical insulin
orders. The strength should only be
listed parenthetically with doses of
U-500 insulin. Educate staff to be
suspicious of an insulin dose that is
exactly 100 units and to verify its
accuracy.
Important change with heparin labels
There will be a transition period
where both labeling styles will be on
the market. To minimize the potential
for medication errors, purchasers
and pharmacy managers should
strongly consider separating the
supplies of “current” and “revised”
ISMP MedicationSafetyAlert!

QAA 1
October – December 2012
ISMP
QuarterlyActionAgenda
Problem
Recommendation
on a per mL basis (5,000 units/mL),
with the volume of the vial appearing in
a different location. Staff have mistaken
the per mL strength as the total dose
contained in a vial, which has led to
heparin overdoses.
heparin, and using all of the “current”
heparin before using products with
the “revised” label.
No.
(21)
Mix-ups have occurred between
liposomal and conventional
formulations of IV amphotericin B.
Conventional amphotericin B
doses should not exceed 1.5
mg/kg/day. Doses of the lipidbased products are higher. Harm,
even death, may result if a mix-up
between the two products occurs.
(21)
A pharmacy received a request for
“Aristra” from the operating room
(OR). Arixtra, a Factor Xa Inhibitor,
was dispensed, but the surgeon
wanted Arista AH, a synthetic,
absorbable hemostatic agent. Arista
AH could not be found in
Micromedex because it is a device, a
factor that contributed to confusion.
Name similarity went unnoticed
during FDA approval because the
products were evaluated by two
different Centers within the agency.
(21,
22,
24)
The recent outbreak of fungal
meningitis cases caused by
contaminated steroid injections
January 24, 2013
Organization Assessment
Action Required/
Assignment
Date Completed
Mix-ups between various formulations of amphotericin B
Communicate orders using both the
proprietary and complete generic name
(e.g., AMBISOME [amphotericin B
liposomal]), and include the reason for
use, the patient’s weight in kg, the mg
per kg dose, and the final dosage
calculation. Restrict the preparation and
dispensing of amphotericin B to the
pharmacy. Dose checking alerts should
be utilized in computer systems for both
liposomal and conventional
formulations. Consider adding a
warning to storage areas of the
conventional form to “question all doses
over 50 mg.”
ARIXTRA (fondaparinux sodium) and ARISTA AH mix-ups
While Arixtra might be used
postoperatively in prevention of
venous thromboembolic events
(VTE) in adults undergoing certain
types of surgery, it isn’t started until
6 hours after the procedure.
Therefore, OR requests for Arixtra
should raise suspicion and require
verification.
Sterile compounding tragedy should spur assessment and action in hospitals
Use commercially available, ready-touse, FDA-approved products from
pharmaceutical manufacturers when
ISMP MedicationSafetyAlert!
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QAA 2
October – December 2012
ISMP
Problem
Recommendation
from a compounding pharmacy
has led to scrutiny in these
facilities. The outbreak should also
lead hospitals to assess their own
internal sterile compounding
practices. A recent study has
shown an overall contamination
rate of 18.2% from fingertip
testing, along with a 5.1%
contamination rate of the
compounded items. Only 13% of
pharmacy school deans feel their
students have been adequately
trained in sterile compounding
prior to graduation.
possible. For medically necessary
products that are not commercially
available, carefully select and utilize a
compounding pharmacy
(www.ismp.org/sc?id=111) or internally
compound the products. Tools are
available to help assess and train staff
in sterile compounding (www.ashp.org,
www.criticalpoint.info/home), including
ISMP’s Guidelines for Safe
Preparation of Sterile Compounds
(www.ismp.org/Tools/guidelines/IVSum
mit/IVCGuidelines.pdf). Establish a
surveillance team to regularly test
compounded preparations and monitor
for compliance with USP <797>.
No.
(24)
QuarterlyActionAgenda
Clinical staff are interrupted as
often as once every 2-5 minutes.
With nurses, error risk increases
12.7% with each interruption and
is doubled if interrupted 4 times
during a single drug administration
and tripled when interrupted 6
times. Distractions and
interruptions include anything that
diverts attention away from the
current task, forcing attention on a
new task at least temporarily.
Attending to the new task
increases the risk of an error with
both the prior task and new task
because the stress of the
distraction or interruption causes
cognitive fatigue, which leads to
omissions, mental slips or lapses,
and mistakes.
Organization Assessment
Action Required/
Assignment
Date Completed
Distractions and interruptions contribute to medication errors
Identify the sources of common
interruptions and remedy any system
issues such as frequently missing
medications; untimely dispensing of
medications; or frequent invalid,
insignificant, or overly sensitive
computer alerts and device alarms.
Provide staff with a quiet area/no
interruption zone with a dedicated
medication room or a cordoned off
area in which to select and prepare
medications. Avoid placement of
automated dispensing cabinets in
hallways or busy nurses’ stations.
Ask all staff to avoid interrupting
other staff members during critical
medication tasks.
New tools on safe injection practices
January 24, 2013
ISMP MedicationSafetyAlert!

QAA 3
October – December 2012
ISMP
QuarterlyActionAgenda
No.
Problem
Recommendation
(25)
The Centers for Disease Control
and Prevention (CDC) has had to
investigate outbreak after outbreak
of life-threatening infections
caused by injection errors. Lack of
initial and continued infection
control training, denial of the
problem, drug shortages, and lack
of appreciation for the
consequences of unsafe injection
practices have all been at the root
of these outbreaks.
The CDC and the Safe Injection
Practices Coalition (SIPC) released
a suite of new materials to help
healthcare providers learn about and
follow safe injection practices
(http://blogs.cdc.gov/safehealthcare/?p
=2802). The tools include
PowerPoint slides, videos, podcasts,
posters, and a press release kit.
Healthcare facilities are encouraged
to use the new tools.
(22)
ISMP has received more than 50
reports of mL-teaspoonful mix-ups.
In the latest event, a nurse
preparing a 2 mg dose of
midazolam syrup measured out 1
teaspoonful instead of 1 mL. The
BD oral syringe she used had both
teaspoonful and mL scales. Oral
syringes with a mL-only scale are
currently not available in 5 mL and
larger sizes.
(23)
Name similarity between clobazam
and clonazePAM has led to
several reports about the potential
for confusion. The drugs share
some similar indications (e.g.,
Lennox-Gastaut Syndrome)
although they have a 10-fold
strength difference in available
dosage forms.
(20)
Certain over-the-counter (OTC)
topical products used for muscle
January 24, 2013
Organization Assessment
Action Required/
Assignment
Date Completed
Teaspoonful—mL mix-ups with midazolam (VERSED) syrup
ISMP has called for limiting the units
of measure to only the metric system
for devices, computer screens,
medication orders, and dosing
instructions on labels. Evaluate the
oral liquid dosing devices used in
your facility, and alert staff to the risk
of measuring errors if both scales
are on the syringe barrel. ISMP has
asked manufacturers of dosing cups
and oral syringes to make available
mL-only devices for hospital use.
Name mix-ups with cloBAZam (ONFI) and clonazePAM (KLONOPIN)
ISMP will be adding the pair of
clobazam and clonazePAM to our
List of Confused Drug Names and
adding cloBAZam to our List of
Look-Alike Drug Names with
Recommended Tall Man Letters in
future revisions. Ensure that this pair
of medications has appropriate
safeguards for differentiation at your
institution.
Topical analgesics and burns
Alert patients to the risk, and advise
them to use these products exactly
ISMP MedicationSafetyAlert!

QAA 4
October – December 2012
ISMP
Problem
No.
and joint pain have caused rare
cases of first- to third-degree
chemical burns. These OTC
products, including Icy Hot,
Bengay, Capzasin, Flexall, and
Metholatum, generally contain
menthol, methyl salicylate, or
capsaicin.
(21)
(20,
23)
The United States Pharmacopeia
(USP) has created a webpage on
outpatient prescription container
labeling (General Chapter <17>) to
guide organizations in the
presentation of information in a
patient-centered manner.
QuarterlyActionAgenda
Recommendation
Organization Assessment
Action Required/
Assignment
Date Completed
as stated on the label and to
discontinue use if they feel actual
pain (rather than a warming
sensation) after applying them.
Additional strategies can be found at:
www.ismp.org/sc?id=103.
USP Prescription Container Labeling standard
If your hospital provides outpatient
prescription services to patients
and/or staff, assess current labeling
procedures to ensure they match the
guidelines (www.ismp.org/sc?id=142).
Reduce readmissions with pharmacy community liaison program and patient education
Medicare is fining hospitals with
External programs offered by
high readmission rates for three
community pharmacies as well as
conditions—heart failure,
hospital-run community liaison
myocardial infarction, and
programs can help hospitals reach
pneumonia. Studies have
their readmissions goals and
identified that adverse drug events decrease preventable ADEs. These
(ADEs) are at the very core of
programs provide in-home or
readmissions. One recent study
telephone support of pharmaceutical
found that warfarin, insulin, oral
care for recently discharged patients.
antiplatelet agents, and oral
Before and after discharge,
hypoglycemic agents account for 7 education should focus on patients
in 10 emergency hospitalizations
who are prescribed a high-alert
among seniors. Another study
medication, especially warfarin,
found that patients with medication insulin, antiplatelet agents, and
discrepancies had a 30-day
hypoglycemic agents. ISMP offers
readmission rate of 14.3%
free patient handouts for several of
compared to 6.1% for patients
these high-alert medications to help
without a discrepancy.
prevent errors and other ADEs with
these drugs (www.ismp.org).
January 24, 2013
ISMP MedicationSafetyAlert!
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QAA 5