January – March 2010
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. Topromotesuch aprocess, the
following selected items fromtheJanuary-March 2010 issues of theISMPMedication Safety Alert! havebeenprepared for an interdisciplinary committeetostimulatediscussion and action toreducetherisk of medication errors. Each item
includes adescription of themedicationsafety problem, recommendations toreducetherisk of errors, and theissuenumber tolocateadditional information as desired. Look for our high-alert medicationicon under theissuenumber if theagendaitem
involves oneor moremedications on theISMPList of High-Alert Medications. TheAction Agendais alsoavailablefor download in aWord format (www.ismp.org/Newsletters/acutecare/articles/ActionAgenda1002.doc) that allows expansion of the
columnsin thetabledesignated for organizational documentation of an assessment, actions required, and assignments for each agendaitem. Many product-related problems can alsobeviewed in theISMPMedicationSafety Alert! section of our Web
siteat: www.ismp.org. Continuing education credit is availablefor nurses at: www.ismp.org/Newsletters/acutecare/actionagendas.asp
Key:
Problem
No.
(5)
ISMP advocates the use of standard
order sets to minimize incorrect or
incomplete prescribing, standardize
patient care, and ensure clarity when
communicating orders. However, if
standard orders are not carefully
designed and maintained to reflect best
practices and ensure clear
communication, they may contribute to
errors. Frequently observed problems
involve incorrect, outdated, ambiguous,
or contraindicated content; format
issues; and failure to approve and
update the order sets. Examples can be
found at:
www.ismp.org/Newsletters/acutecare/
articles/20100311.asp.
(5)
In 2006, a 16-year-old pregnant patient
at a Wisconsin hospital was tragically
given an infusion of epidural bupivacaine
and fentaNYL intravenously. Following
the incident, which led to criminal
charges for the nurse involved, the
hospital invited ISMP to conduct an
independent root cause analysis of the
event, which identified four proximate
causes and dozens of underlying system
causes and performance shaping factors
April 8, 2010
—ISMP high-alert medication
Recommendation
Organization Assessment
Improperly designed order sets can lead to errors
Action Required/ Assignment
Date Completed
ISMP has created Guidelines for
Standard Order Sets in the form of a
checklist
(www.ismp.org/Tools/guidelines/default.
asp), which can be used by
interdisciplinary teams to evaluate all
current orders sets and design new
order sets. The guidelines pertain to
written and electronic order sets.
Epidural bupivacaine and fentaNYL given intravenously leads to death
In cooperation with hospital leadership,
the analysis appears in the April 2010
issue of The Joint Commission Journal
on Quality and Patient Safety. Full text of
the article is available free at:
http://psnet.ahrq.gov/resource.aspx?reso
urceID=17785&sourceID=1&emailID=19
328. Healthcare organizations are
encouraged to review the analysis to
identify similar potential failure points in
their own systems and implement
ISMP MedicationSafetyAlert!

QAA 1
January – March 2010
QuarterlyActionAgenda
(5)
In events reported to the Pennsylvania
Patient Safety Authority involving insulin
products, 52% have led to situations in
which a patient received the wrong dose
of insulin or had a dose of insulin
omitted.
(3)
A new nurse in the emergency
department helped a busy colleague
by preparing an insulin infusion in a
5 units/mL concentration, following
instructions in the drug reference
attached to the dispensing cabinet.
But the hospital’s standard
concentration for insulin infusions
was 1 unit/mL. Although the bag was
properly labeled, the concentration
was not reviewed during handoff to
the receiving nurse, who started the
infusion according to the hospital’s
standard concentration.
ISMP
Recommendation
Organization Assessment
recommended risk-reduction strategies.
Errors with insulin
To identify and monitor problems
associated with insulin, the Authority has
posted a sample tool on its Web site:
www.patient
safetyauthority.org/Educational
Tools/PatientSafetyTools/insulin/Pages/
home.aspx. Consider utilizing this tool to
document facility-specific process and
outcome measures involving the use of
insulin.
Wrong concentration of IV insulin infusion
Ideally, pharmacies should prepare
infusions that are not commercially
available. When 24-hour pharmacy
coverage is not an option, or under
conditions that warrant immediate
use, up-to-date hospital-approved
drug guidelines for IV admixtures
prepared by nurses should be readily
available, and nurses should be
educated about the procedures.
Nurse-prepared infusions, especially
with high-alert drugs, should be
independently checked after
preparation and during handoffs.
(2)
A patient was hospitalized after
receiving a significant overdose of
intrathecal baclofen. The patient’s
physician had accidentally
programmed a Medtronic
SynchroMed II implantable pump to
administer an extra dose every hour
rather than every morning. Medtronic
had previously distributed a letter via
its sales force to warn about
programming errors and announce
Baclofen programming error with SynchroMed II pump
If your inpatient or outpatient
providers care for patients with
SynchroMed pumps, please check
that the latest software updates for
the N’Vision Clinician Programmer
have been received. How-ever, do
not rely on the updates alone to
prevent errors. The total dose and
percent of change from the prior
dose are visible on a summary
screen, but there is no alarm or stop
No.
Problem
that led to the tragic event.
April 8, 2010
ISMP MedicationSafetyAlert!

Action Required/ Assignment
Date Completed
QAA 2
January – March 2010
QuarterlyActionAgenda
No.
(1)
(4)
Problem
software modifications. The letter
had not reached the physician, and
software modifications had not been
provided.
Two minibags were accidentally
prepared with vecuronium instead of
valproate sodium injection. Both
medication vials were nearly the
same size with red caps and had
been stocked close to one another in
the pharmacy. The patient was able
to alert the nurse when it became
difficult to breathe, and the infusion
was stopped.
ISMP
Recommendation
Organization Assessment
feature for critically high or low
doses. An independent double-check
to ensure accurate programming is
needed. Advise emergency
department staff to consider an error
if patients with implantable pumps
report a recent refill or programming
change.
Mix-up between vecuronium and valproate sodium injections in the pharmacy
Sequester neuromuscular blockers
in a secure, lidded bin (or a
separate, lidded dispensing cabinet
compartment) labeled “Paralytic
Agent” in the pharmacy and any
patient care locations where needed
(e.g., ED, PACU, ICU). Some
hospitals also apply a ShrinkSafe
sleeve to the vials to warn about the
drug’s paralytic nature; how-ever,
use on multiple neuromuscular
blockers can make them look similar
and contribute to mix-ups.
Minimizing the variety of
neuromuscular blockers will help
reduce similarity in appearance (with
or without the sleeves).
Action Required/ Assignment
Date Completed
ADEs with rosiglitazone (AVANDIA), QUEtiapine (SEROQUEL, SEROQUEL XR), and testosterone gel
During the 3rd quarter of 2009,
If patients are discharged on
ISMP’s Quarter-Watch identified
rosiglitazone, alert them to
adverse drug events (ADEs)
cardiovascular risks and symptoms
frequently reported to FDA.
to report to their doctor. Advise
Rosiglitazone ranked highest with
diabetic patients discharged on
more than 1,000 reports of patient
QUEtiapine to monitor their blood
deaths, reinforcing concerns about
glucose closely, and patients without
its cardiovascular safety. QUEtiapine diabetes to report signs of diabetes
ranked second with 977 reports of
to their doctor. If using testosterone
serious or fatal events, caused
gel upon discharge, patients should
mostly by a link between the drug
be reminded to keep the application
and development of diabetes.
site covered, wash their hands after
April 8, 2010
ISMP MedicationSafetyAlert!

QAA 3
January – March 2010
QuarterlyActionAgenda
No.
Problem
Despite FDA warnings about offlabel use of testosterone gel in
women and accidental exposure to
children, 155 reports were received
involving exposure to women and 22
reports involving children.
ISMP
Recommendation
application, and to be cautious
around pregnant women.
Organization Assessment
Action Required/ Assignment
Date Completed
Designing a Medication Error Reduction Plan (MERP)
ISMP encourages hospitals outside
of CA to consider adopting a similar
program to significantly impact
patient safety. Details regarding the
required components of the MERP in
CA along with self-assessment
questions for evaluation of the plan
can be found at: www.ismp.org/
Newsletters/acutecare/articles/20100
325.asp
(6)
To reduce medication errors, every
hospital in California (CA) was
required to implement a MERP
approved by the CA Department of
Public Health by January 2005.
Essential features of the MERP
include assessing, improving, and
evaluating medication safety. CA
hospitals are also required to
incorporate and learn from external
medication-related errors and take
action to prevent them.
(3)
Two children received levetiracetam
instead of levocarnitine in error after
a technician selected the wrong drug
from an alphabetical pick-list during
order entry. Both drugs have the
same elixir strength and are dosed
similarly in children. Neither child
was harmed, but a patient on
levetiracetam could experience a
seizure if given levocarnitine in error.
Use both brand and generic names
when prescribing these drugs, along
with the indication. Add these to your
list of look-alike drug names and
build software alerts to warn about
confusion. Another strategy is to
change levocarnitine to L-carnitine in
drug databases, or take other
measures to differentiate these
drugs in pick-lists.
(6)
Space ran out on the first line of
directions when entering an
electronic prescription that printed in
the pharmacy, and the word “until”
was split on the prescription so that
the “l” appeared on the next line. A
technician mistook the letter l as the
number 1, which altered the
e-Rx error caused by a truncated/broken word
Check your electronic systems to
determine if words or numbers
truncate/break onto different lines,
potentially causing a problem on
screens, labels, and MARs. If you
identify problems, alert your vendor
and send ISMP examples through
our Medication Errors Reporting
Drug name mix-up between levetiracetam (KEPPRA) and levocarnitine (CARNITOR)
April 8, 2010
ISMP MedicationSafetyAlert!

QAA 4
January – March 2010
QuarterlyActionAgenda
No.
Problem
directions for duration of therapy
from “7” days to “17” days.
(5)
PharMEDium shipped ropivacaine in
sodium chloride in a carton that
contained CADD cassettes with 3
different lot numbers and expiration
dates. The pharmacy technician
assigned the same expiration date to
all the cassettes while loading them
in a dispensing cabinet. Products
from other outsourcing companies
have also been shipped in this
manner.
(1)
The rate of infusion for an IV
diltiazem solution was unknown, so a
pharmacist selected “UD” (ut dictum
or “as directed”) from a drop-down
list to populate the rate field. The
nurse thought “UD” meant “unit
dose” and ran the infusion at 125
mg/hour. Nurses polled after the
event also thought UD meant unit
dose. The patient died after receiving
the infusion.
(6)
Ampicillin 2 g and nafcillin 2 g ADDVantage containers from Sandoz
look nearly identical.
(2)
During hospitalization, “vitamin D”
was erroneously entered into the
allergy field of a patient’s medical
record. On subsequent visits, the
erroneous information remained in
April 8, 2010
ISMP
Recommendation
Organization Assessment
Program (MERP)
(www.ismp.org/orderforms/reporterro
rtoismp.asp).
Carton may hold multiple lot numbers and expiration dates
Educate pharmacy staff regarding
the potential for products with
different expiration dates to be
shipped in the same carton. ISMP
recommended to outsourcing
companies that a more prominent
auxiliary label be placed on the outer
carton if products with differing
expiration dates if they are shipped
together.
Action Required/ Assignment
Date Completed
Ambiguous and dangerous abbreviation “UD”
The Latin abbreviation “UD” should
not be used as it is too easily
confused with “unit dose.” Consider
requesting that your computer
system vendor eliminate the ability to
enter “UD” in the rate field.
Prescribers should provide complete
orders; pharmacists should clar-ify
incomplete orders.
Look-alike Sandoz ADD-Vantage antibiotics
If you use ADD-Vantage antibiotics
in your facility, circle or highlight the
drug name on the container to draw
attention to it. Consider purchasing
one of these products from a
different manufacturer.
Removing inaccurate allergy information from electronic records
Clinicians and IT staff should be
educated regarding their
organization’s process for correcting
electronic information. This process
should be streamlined and
ISMP MedicationSafetyAlert!

QAA 5
January – March 2010
ISMP
No.
(4)
Problem
the record. Practitioners in clinical
areas could not correct the medical
record; only an IT programmer could
make the correction.
Certain Baxa oral syringes make it
difficult to measure doses. For
example, the the 5 mL amber oral
syringe marks 1/4 teaspoon at 1.2
mL instead of 1.25 mL. And some
numbers on the 3 and 5 mL clear
plastic oral syringes do not align with
the correct calibration markings. The
problems have been addressed, but
wholesalers may still be shipping
these problematic syringes.
April 8, 2010
QuarterlyActionAgenda
Recommendation
standardized as much as possible
without jeopardizing the integrity and
security of electronic information.
Organization Assessment
Action Required/ Assignment
Date Completed
Inaccurate measurement is possible when using certain Baxa oral syringes
Assess your supply of oral syringes
and inform nurses about these
issues if you have affected syringes.
Advise practitioners to measure
doses in mL due to the misalignment
of the teaspoonful markings.
Consider seeking inventory from
another manufacturer temporarily,
although there may be limited
options due to the national shortage
of oral syringes.
ISMP MedicationSafetyAlert!

QAA 6