Download to open the MS Word version of the Quarterly Action Agenda

July – September 2016
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 July–
September 2016 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 brief description of the medication safety problem, a few 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 List of High-Alert Medications (www.ismp.org/sc?id=479). The Action
Agenda is also available for download in a Microsoft Word format (www.ismp.org/newsletters/acutecare/articles/ActionAgenda1604.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. Continuing education credit is available for nurses at: www.ismp.org/sc?id=480.
Key:
—ISMP high-alert medication
Organization
Action Required/
Assessment
Assignment
Official prescribing information for HUMULIN R U-500 (insulin regular injection) updated after FDA approval of U-500 syringe from BD
(14, After years of errors when using U-100 Make sure patients who will be using U19) or tuberculin (TB) syringes to measure
500 insulin vials upon discharge are also
and administer U-500 insulin, a U-500
prescribed U-500 syringes, and that
insulin syringe should be on the market prescribers order the dose in actual units
beginning in November 2016. Updated and not in “U-100” units or by volume.
prescribing information for HumuLIN R For hospitals that will not stock the UU-500 no longer provides a conversion 500 insulin syringe because it does not
table for using U-100 or TB syringes and contain a safety needle, the HUMULIN R
states that patients using vials must be U-500 KWIKPEN is available as an
prescribed the U-500 syringe to avoid
alternative. Unless dispensing a U-500
errors. However, the U-500 syringes
pen, U-500 insulin doses should be
will not have a safety needle, which
prepared in and dispensed from the
may preclude its use in hospitals.
pharmacy.
NeoMed and Medtronic low dose tip ENFit syringes get US Food and Drug Administration (FDA) clearance
(16) The new low dose ENFit syringes, along Consider using a DoseMate add-on
with regular ENFit syringes, allow the
device with the NeoMed low dose tip
industry to adopt the ENFit system to
syringes to cover the flanges when
prevent misconnections between
administering oral medications to
No.
October 6, 2016
Problem
Recommendation
ISMP MedicationSafetyAlert!

Date
Completed
QAA 1
July – September 2016
ISMP
QuarterlyActionAgenda
Organization
Assessment
Problem
Recommendation
enteral and parenteral systems.
However, mouth injuries are a concern
with neonates when using the NeoMed
low dose tip syringe for oral
administration due to flanges near the
syringe tip that prevent connection to a
tracheostomy tube opening. Also,
screw-on transfer lids and plug-in
stepped stoppers used to transfer drugs
from bottles to syringes are not childresistant.
neonates until other efforts to resolve
concerns with the flanges are
completed. Recommend the use of an
ENFit dosage straw in conjunction with
a child-resistant bottle closure for
home use until child-resistant caps
compatible with ENFit syringes are
available.
No.
Action Required/
Assignment
Date
Completed
Cisatracurium is available in two concentrations
In the pharmacy, stock the two
concentrations in separate locations.
Store the 200 mg/20 mL vials intended for
compounding with IV room supplies, and
include a warning label, “NOTE-HIGH
CONCENTRATION. For pharmacy
compounding use only.” When possible,
use barcode scanning to verify that the
correct concentration is used during
compounding or is dispensed.
(17) Cisatracurium is available in 2 mg/mL
and 10 mg/mL concentrations. The 2
mg/mL concentration is used during
intubation. The 10 mg/mL
concentration is used to compound
continuous infusions. Anesthesia
administered a 5-fold overdose after
the pharmacy accidentally dispensed a
200 mg/20 mL (10 mg/mL) vial to the
operating room. Anesthesia was not
aware the drug was available in a 10
mg/mL concentration.
Recent patient-controlled analgesia (PCA) by proxy event suggests reassessment of practices may be necessary
(19) A hospital employed “safety
Healthcare facilities should reassess their
companion” activated PCA doses for an policies and practices regarding proper
elderly postoperative patient who was
patient selection to make sure patients
agitated and hallucinating. The safety
have the mental alertness and cognitive,
companion was unaware that the PCA
physical, and psychological ability to
doses should be delivered by only the
manage their own pain. Make sure
patient. Analysis of the event
policies and practices related to patient
October 6, 2016
ISMP MedicationSafetyAlert!

QAA 2
July – September 2016
ISMP
Problem
No.
uncovered several causative factors:
patient selection criteria for PCA was
not enforced, policies did not specify
who could/could not activate a dose, a
warning no longer appeared on the PCA
cord to warn that only patients could
press the button, and staff had limited
awareness about the dangers of PCA by
proxy.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
monitoring are clear about how to
identify and act when a patient has
respiratory insufficiency due to opioid
toxicity. Educate patients, family, and
staff, and place warning signs on PCA
cords that only the patient can press the
button.
National Alert Network (NAN) alert about syringe leakage
(19) We have received multiple reports
Look for fluid leakage during the syringeabout various BD syringe sizes in which filling process, and discard any syringes
the drug has leaked beyond the syringe that contain fluid that has leaked past the
plunger onto surfaces exposed to air.
black stopper on the plunger. The syringe
This happens most frequently when the lot number should be identified, and such
plunger and barrel are not vertically
instances should be reported to the FDA
aligned while filling the syringe. If fluid
MedWatch program
has leaked past the black stopper on
(www.ismp.org/sc?id =1660), ISMP
the plunger, the contents may be
(www.ismp.org/MERP), and the syringe
contaminated, or healthcare workers
manufacturer.
could be exposed if the drug is
hazardous.
EPINEPHrine and infant 4.2% sodium bicarbonate injection mix-up during neonatal code
(14) A nurse inadvertently prepared a
Hold mock codes to identify potential
prefilled syringe of infant 4.2% sodium
problems like this and to familiarize
bicarbonate injection instead of the
practitioners with items in the code cart.
EPINEPHrine requested by a physician
Train staff to immediately remove
during a neonatal code. Three doses of packing slips at the beginning of a code so
the wrong medication were given. The they won’t obscure visibility. Have
error may have been partly due to the
different practitioners prepare and
crash cart tray packing slip covering the administer drugs during codes to provide
EPINEPHrine carton labels. Also, the
an opportunity for a verbal and visual
October 6, 2016
ISMP MedicationSafetyAlert!

QAA 3
July – September 2016
ISMP
Problem
No.
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
sodium bicarbonate syringe labels may
have been oriented upside down from
the nurse’s point of view.
confirmation by a second practitioner.
Include pharmacists on code teams to
help prepare necessary medications.
FDA allows bleomycin injection to be imported during shortage
(15) During a shortage, imported bleomycin Make sure staff are aware of the label
sulfate powder for injection 15,000
differences and the difference between
international units will be available
units and international units for this
(equal to 15 units of bleomycin
product. Have pharmacy apply barcodes
injection, USP). The label refers to the
to these imported bleomycin vials.
drug as BLEO 15K, does not have a
barcode, and expresses the dosage in
international units instead of units.
Cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls/vials and unprepared consumers
(16) The excessive cost of EPINEPHrine auto- If your organization has replaced, or plans
(18) injectors has led consumers to do
to replace, EPINEPHrine auto-injectors
without the medication, use a single
with ampuls/vials, provide patient care
device for multiple family members, or
areas (not patients) with an anaphylaxis
rely on expired products. As an
kit containing a 1 mL vial or ampul of
alternative, the media has publicized
EPINEPHrine (1 mg/mL), a syringe, and
ways for consumers to construct an
other needed supplies, along with
EPINEPHrine anaphylaxis treatment kit
directions for measurement of the dose
using a 1 mg vial of EPINEPHrine,
and administration by the correct route.
syringe, and needle. However, this may Conduct simulation training using the kit
lead to administration of the entire 1 mg so practitioners are comfortable with
vial of the drug. High costs have also
preparing and administering EPINEPHrine
spurred organizations to replace the
from a vial or ampul. Due to the possibility
auto-injectors with ampuls and/or vials. of overdose, the use of vials by consumers
ISMP recently received reports involving is not a viable alternative to the
the administration of EPINEPHrine 1 mg EPINEPHrine auto-injectors.
IV instead of 0.3 mg IM, after switching
from auto-injectors to vials.
October 6, 2016
ISMP MedicationSafetyAlert!

QAA 4
July – September 2016
ISMP
QuarterlyActionAgenda
Organization
Assessment
Correct use of inhalers: Help patients breathe easier
(14) Most patients with asthma and chronic If patients are not responding as
obstructive pulmonary disease use their expected, ask to observe their inhalation
inhalers incorrectly leading to
technique. Remind patients to discard an
diminished drug delivery, omitted
inhaler when the dose count is zero, even
doses, overdoses, and exacerbation of
if the device continues to spray.
the underlying disease and respiratory
Demonstrate proper use during patient
symptoms. Depending on the inhaler
education and counseling and request
type, examples of common errors
patient return demonstration. Provide
include inhaling at the wrong time (not patients with access to videos on the
in sync with pressing the inhaler), using proper use of inhalers. Educate
an empty inhaler, and swallowing the
practitioners regarding common error
capsule containing the inhalation
types. See the newsletter article for a 2medication. Design enhancements of
page chart of safety tips for patients
the newer inhalers have improved
using the newer inhaler types. Post
correct use but errors still persist.
this chart for staff reference.
Automation bias and complacency affect decision making when using technology
(18) When typing “dil” for DILANTIN
Improve the reliability of the technology
(phenytoin) into a pharmacy system,
itself and support clinicians to more
dilTIAZem was selected in error from
accurately assess the reliability of
the drop-down menu and dispensed.
technology so appropriate monitoring
The nurse obtained the drug from an
and verification strategies can be
automated dispensing cabinet (ADC).
employed. Limit the amount of human
She noticed the handwritten “Dilantin” input needed to use the technology, and
on the medication administration
design it in a manner that reduces overrecord but accepted the information on reliance. For example, if an order entry
the ADC screen as correct because it
system provides choices after entering
was automated. This is an example of
the first 3 letters of the drug name, then
automation bias, when users favor the
consider forcing it to require 4 or 5 letters
output of technology over a manual
of a drug name and the product strength
source of information. A similar bias,
before it will suggest choices. Train staff
automation complacency, occurs when about technology limitations and
No.
October 6, 2016
Problem
Recommendation
ISMP MedicationSafetyAlert!

Action Required/
Assignment
Date
Completed
QAA 5
July – September 2016
ISMP
No.
Problem
QuarterlyActionAgenda
Organization
Assessment
Recommendation
Action Required/
Assignment
Date
Completed
users fail to monitor technology output, opportunities for error.
believing it to be accurate.
Don’t abbreviate drug names in computerized prescriber order entry (CPOE) systems
(17) Space limitations in CPOE drug name
For these and other combination
fields can be problematic for
products, display both the brand and
combination products. In one hospital, generic names of the drug when
GENVOYA (elvitegravir, cobicistat,
possible and do not abbreviate the
emtricitabine, tenofovir alafenamide)
drug names.
was abbreviated as “Elviteg-CobicEmtricit-TenofAF” in the CPOE system,
which led to mix-ups with STRIBILD
(elvitegravir, cobicistat, emtricitabine,
tenofovir disoproxil fumarate). The two
drugs are not interchangeable.
Vaccine errors associated with age-related factors
(15) Analysis of 4 years of vaccine error
Purchase age-specific formulations from
reports submitted to ISMP found that
different manufacturers so they look
age-related contributing factors were
dissimilar. Separate pediatric and adult
linked to more than 1 in every 3 reports. vaccines and those with similar labels,
Causes include confusion between
names, or overlapping components. Use
numerous age-dependent vaccines that auxiliary warning labels to draw attention
target the same diseases (especially
to vaccines which come in multiple age
influenza virus vaccines, Haemophilus
formulations. Label the specific locations
influenzae type b vaccines, hepatitis A
where vaccines are stored to facilitate
and B vaccines, combination vaccines
correct, age-specific selection. Post
that target diphtheria, tetanus, and
immunization schedules in clinical areas.
pertussis); unfamiliarity with the
Ask patients or parents to help verify age
vaccine-specific recommended age; not by reading the Vaccine Information
verifying the patient’s age prior to
Statement (VIS) and checking the specific
administration; and similar vaccine
age range for the vaccine.
abbreviations, packaging, and labeling.
October 6, 2016
ISMP MedicationSafetyAlert!

QAA 6
July – September 2016
ISMP
QuarterlyActionAgenda
Organization
Action Required/
Assessment
Assignment
Storage and reconstitution differ for CUBICIN and CUBICIN RF by Merck
(19) A pharmacist ordered Cubicin from a
The original Cubicin product will be
wholesaler but received Cubicin RF
phased out, but it is important to be
instead, a newer form of DAPTOmycin. aware of the differences between the
Cubicin RF should be stored at room
new and old formulation and any
temperature and reconstituted with
generics that may become available on
bacteriostatic or sterile water for
the market.
injection. Cubicin must be refrigerated
and reconstituted with normal saline.
American Academy of Pediatrics, Textbook of Neonatal Resuscitation, uses volumetric dosing
th
(19) The 7 edition of this textbook refers to We recommend against the use of
the dose of EPINEPHrine in terms of
volumetric dosing and have notified the
mL/kg (page 189). But, there are two
textbook publishers of our concerns.
commercially available concentrations
Dosing tables should be used during
of EPINEPHrine: 1 mg/mL and 0.1
codes, which automatically calculate the
mg/mL. It may be unclear that the
dose and volume based on the patient’s
volumetric dosing refers only to the 0.1 weight and drug concentration.
mg/mL solution. Another problem is
that mL/kg dosing is uncommon and
may be misread as mg/kg.
No.
October 6, 2016
Problem
Recommendation
ISMP MedicationSafetyAlert!

Date
Completed
QAA 7