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 2013 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 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/actionagenda1304.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: ISMP high-alert medication No. Problem Recommendation FentaNYL patch fatalities linked to bystander apathy (16) A 15-month-old child who had been sleeping No patient should walk out of a doctor s with his mother gained access to her fentanyl office, hospital, clinic, or pharmacy without patch, ingested it, and was found face-to-face instructions on the use of unresponsive when his mother awoke. He fentanyl patches and related safety later died. Similar events prior to this have concerns. All health professionals must been just as tragic, yet little has been done to individually instruct patients and caregivers assure patient education about proper use and and not rely on others to do it. ISMP has storage of fentanyl patches. Until every developed a FREE patient education healthcare professional and health system checklist and consumer leaflet for use during accepts personal responsibility for promoting consumer education that can then be given to safe use of this drug, we are exposing one of the patient for reference (download the the most troubling examples of bystander checklist/leaflet at: apathy in healthcare: a belief that we don t www.ismp.org/ahrq/default.asp [must need to intervene because others will. register for initial access]). Death and neurological devastation when IV vinca alkaloids are given intrathecally (18) Results from the ISMP International Medication Safety Self for Oncology revealed that only 54% of US Dispense IV vinca alkaloids in a minibag of a compatible solution and never dispense and/or administer these drugs using a hospitals dispense vincristine in a minibag of compatible solution to prevent accidental intrathecal administration. To date, there are 120 published cases of administration of vincristine by the intrathecal route when the drug was dispensed in a syringe, and zero cases when dispensed in a minibag. Most events were related to mistaking IV vincristine for an intrathecal medication syringe. Prohibit IV vinca alkaloids in areas where intrathecal medications are administered and/or stored. Confirm that any prescribed intrathecal medications have been administered before dispensing IV vinca alkaloids. For more recommendations, visit: www.ismp.org/ newsletters/acutecare/showarticle.asp?id= 58. (e.g., methotrexate, cytarabine). October 3, 2013 ISMP MedicationSafetyAlert! QAA 1
Stock ketamine in a lower concentration (10 mg/ml) in the emergency department (ED) (14) A pediatric patient received a 10-fold In the ED, ketamine is often administered IV, overdose of ketamine in the ED. A small volume (0.175 ml) of ketamine (100 mg/ml) was needed for the child s dose. The nurse doubted that such a small volume was needed and drew up 1.75 ml, which he considered to be a more normal volume. so a lower concentration (10 mg/ml) should be stocked. Concentrated ketamine products, which result in lower dosing volumes, may be more appropriate for IM or intranasal (offlabel) use since larger doses are needed with these routes. Automated maximum dose alerts with hard stops for amphotericin B, methotrexate, and fentanyl (19) ISMP has often written about mix-ups between conventional and lipid-based amphotericin B, accidental daily dosing of oral methotrexate, and dosing errors with IV fentanyl. Recent errors with these drugs led to the death of a patient who received conventional amphotericin B in a dose for the lipid-based product, and serious injuries to two toddlers one of whom received methotrexate daily for 7 days and the other an IV fentanyl overdose after a pump misprogramming error. Design hard stops in order entry computers for doses of conventional amphotericin B greater than 1.5 mg per kg or catastrophic limits, and for daily dosing of oral methotrexate without a stop date after 5 days or less. Program hard stops in smart infusion pumps to detect pump programming errors that would lead to catastrophic doses with fentanyl. The intent is to halt the process or allow for a brief period of investigation to ensure safety. (16) Experts agree that hepatitis B can be eliminated in the US with proper vaccination. Yet, one in three newborns leaves the hospital without receiving this vaccination, and 800 become infected with hepa-titis B each year because of perinatal exposure. Help end hepatitis B by vaccinating newborns Ensure that hepatitis B vaccine birth doses are included in standard order sets, universally administered before hospital discharge, and that proper follow-up occurs with a total of 3 or 4 doses at properly spaced intervals. (14) A pharmacy technician mixed 0.27 ml of a diluent with 5.13 ml of magnesium sulfate, mixing up the volumes required (0.27 ml magnesium, 5.13 ml diluent). The syringe Syringe pull-back method of verifying IV admixtures unreliable ISMP s compounding safety guidelines strongly dis-courage the syringe pull-back method of verifying the contents of admixtures, particularly for compounded sterile products October 3, 2013 ISMP MedicationSafetyAlert! QAA 2
pull-back method was used for checking the admixture, so the error went unnoticed because it was not clear which syringe was associated with which vial. The syringe pull-back method for checking admixtures is unreliable. (17) Staff training is critical to optimize the use of new technology, employ all its safety features, and prevent misuse that might lead to errors. But users rarely read the vendors directions for use, and organizations may not have the depth of knowledge to teach staff how to properly use the technology. Users tend to first learn what they need to know to do their jobs, and then all that is feasible with the technology. This second wave of training also may be more effective when partnering with the vendor. with high-alert drugs (www.ismp.org/sc?id=251). The contents of these solutions should be verified immediately before adding them to the diluent, and syringes should be labeled if verification is not completed shortly after drawing the solution into the syringe. Developing productive partnerships with technology and device vendors to improve staff training Work collaboratively with technology vendors to deliver initial staff training and periodic follow-up training. Make sure your purchasing agreement clearly details the training to be provided. Develop written expectations to set the ground rules (e.g., no marketing beyond agreed scope). Conduct a failure mode and effects analysis and use the results to plan the training. All training should be coordinated by the pharmacy or nurse educators in collaboration with the vendor. (17) A PROSTIN E2 20 mg vaginal suppository was cut in half and used in place of a CERVIDIL 10 mg vaginal insert intended to promote cervical ripening in a pregnant women. The Cervidil insert provides a gradual release of the drug and can be removed. The suppositories, which cause tetanic contractions, are used to evacuate uterine contents after a missed abortion or fetal death. In this case, fetal heart deceleration led to an emergency C-section. Dinoprostone dosage forms (PROSTIN E2 and CERVIDIL) confused Prostin E2 should not be available on nursing units and should only be dispensed from the pharmacy after the indicated use has been verified. Staff who might encounter pregnant women should be warned that, although the generic name for both products is the same, Prostin E2 should only be used for intrauterine fetal death and termination of pregnancy, not for cervical ripening. (14) Certain procedures performed in utero may require administering drugs directly to the In utero medication administration to fetus presents unique safety challenges Establish a process for prescribing fetal medications (e.g., temporary record, October 3, 2013 ISMP MedicationSafetyAlert! QAA 3
fetus. Because the fetus may not have a medical record, drugs intended for the baby are sometimes ordered on the mother s chart. In preparation for an intrauterine transfusion to a fetus, a neuromuscular blocking agent was ordered for the fetus to keep the baby still. The medication, which had been ordered on the mother s chart, was administered IV to the mother, leading to respiratory arrest. The mother died and the infant sustained CNS impairment. generic record for Baby Doe using the mother s identifier). Avoid prescribing fetal drugs on the mother s record. Develop order sets for fetal medications. Pharmacy preparation and labeling should make it clear that the drug is intended for the fetus. Require a time-out process to verify all information before fetal drug administration. (18) Errors involving 10-fold topotecan overdoses have been reported. Several of these errors have occurred because the decimal point in the dose was overlooked (e.g.,.7 mg dose misread as 7 mg; 2.5 mg dose misread as 25 mg) or because a trailing zero was used after a whole number dose ( 4.0 mg misunderstood as 40 mg). Avoiding topotecan 10-fold overdoses Always include a leading zero (e.g., 0.7 mg) and avoid using trailing zeros (e.g., 2 mg, not 2.0 mg) when expressing doses. Include the intended dose in mg/m 2 and the total calculated dose to allow other clinicians to verify the dose. Consider the use of standardized order sets to avoid topotecan dosage confusion. (16) Several bleeding reversal products have been referred to as Prothrombin Complex Concentrate or PCC, but there is a new product, KCENTRA, with the proper name of Prothrombin Complex Concentrate. The use of Prothrombin Complex Concentrate or PCC may result in confusion regarding which drug is intended. Confusion a factor with PCC orders Determine which of these reversal products will be on the formulary and educate staff about each agent and the risk of confusion when using the terms Prothrombin Complex Concentrate or PCC. Always clarify orders for Prothrombin Complex Concentrate or PCC in order to determine the specific brand name. FLEET ENEMA SALINE (dibasic and monobasic sodium phosphate) contains phosphates, not plain saline (15) Fleet Enema Saline contains sodium Avoid Fleet enemas in elderly patients with October 3, 2013 ISMP MedicationSafetyAlert! QAA 4
phosphate monohydrate 19 g and dibasic sodium phosphate 7 g. Because the label states saline, the phosphate content may be overlooked. Phosphate toxicity is possible from even a single enema, although elderly patients with renal insufficiency, those using more than one enema per 24 hours, and patients with decreased intestinal motility are more at risk. renal insufficiency and those with diseases that slow intestinal motility. When used for other patients, the enema should be immediately expelled, and a second dose within 24 hours should not be administered. Patients should be warned to carefully follow label directions and to avoid using more than one enema in 24 hours. (15) Medication errors in a LTC facility often originate in the hospital. For example, unnecessarily including the strength of insulin (100 units per ml) without the actual dose on a transfer form led a LTC nurse to misunderstand a new resident s dose as 100 units, which led to his death. Studies show inconsistencies between medications on discharge summaries and transfer forms, leading to error rates of 21% or more during transitions between hospitals and LTC, particularly with warfarin, insulin, opioids, and cardiovascular drugs. (19) A young patient was transitioned from morphine PCA, using a CADD-Solis Ambulatory Infusion Pump, to oxycodone as needed for pain. The nurse stopped the infusion and turned the pump off, but left the patient connected in case the transition from PCA was not tolerated. These pumps do not feature an auto-lock function, allowing the patient to turn the pump back on and administer bolus doses every 15 minutes. Protecting vulnerable patients during handoffs to long-term care (LTC) Establish a list of drugs that are often not continued after hospitalization and refer to the list during discharge medication reconciliation to determine if clarifications are needed. Require prescribers to verify transcribed discharge sum-maries, and coordinate completion of the transfer/ referral form with the discharge summary to ensure consistency. Have pharmacists review the prescribed medications for patients being transferred to LTC facilities. Pump resumes patient-controlled analgesia (PCA) dosing when turned off then on again If you use these pumps, disconnect the patient from the pump and/or remove the medication cassette if PCA is discontinued. Another option is to reset the PCA dose and continuous infusion rate to zero prior to shutting off the pump, so if it is turned back on, a security code is needed to modify the pump settings. You can also remove the battery pack, although this option may lead to lost batteries and delayed therapy. Drug shortage leads to preparation of wrong strength of levothyroxine (14) A pharmacy was unable to obtain vials of Hospitals should have a plan in place for October 3, 2013 ISMP MedicationSafetyAlert! QAA 5
No. Problem Recommendation levothyroxine 500 mcg and ordered 100 mcg vials instead. Upon reconstituting the drug with 5 ml, a tech-nician failed to notice the strength and prepared the drug as usual. He labeled the vial as containing 100 mcg/ml but it contained 20 mcg/ml. how product replacements are used during a shortage, and how changes are communicated to staff. For additional strategies to avoid errors during drug shortages, visit: www.ismp.org/ Newsletters/acutecare/articles/20101007.a sp. October 3, 2013 ISMP MedicationSafetyAlert! QAA 6