ISMP Medication Safety Alert

January – March 2007 ISMP QuarterlyActionAgenda One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and use that information to prevent similar problems at your practice site. To promote such a process, the following selected agenda items have been prepared for your senior leaders and an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. These agenda topics appeared in the ISMP Medication Safety Alert!between July and September 2007. Each item includes a brief description of the medication safety problem, recommendations to reduce the risk of errors, and the issue number in parentheses 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. Many product-related problems can be viewed in the ISMP Medication Safety Alert!section of our website. Continuing education credit is available for nurses at: http://www.ismp.org/Newsletters/acutecare/actionagendas.asp.

Key: — ISMP high-alert medication No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment Fatal 1,000-fold overdose of zinc in TPN due to confusion between mcg and mg (18) A fatal 1,000-fold overdose of Standardize the way zinc sulfate zinc sulfate contained in a TPN (and other electrolytes) is solution was administered to a prescribed. Ensure that the preterm neonate. A calculation prescribed dosing method matches was made to convert zinc, the dosing method required for prescribed in mcg/100 mL, to order entry into pharmacy mcg/kg, which was required for software. Add low-volume trace the automated compounder elements to TPN admixtures software. The calculation was manually. Build and heed dose correct, but it was entered warnings in automated incorrectly into the pharmacy compounders and pharmacy computer as mg, not mcg. software. Develop comprehensive Several system failures education modules and validate contributed to the error, the competency of individuals including nonstandard ways of involved in TPN. See the full article prescribing electrolyte additives with additional recommendations in TPN and inadequate check at: www.ismp.org/ systems. Newsletters/acutecare/articles/200 70906.asp. Inappropriate prescribing of FENTORA (fentanyl buccal tablets)

April 19, 2007 ISMP MedicationSafetyAlert! QAA 1 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment (19) Fentora has been linked to Make FDA's Healthcare serious adverse outcomes, Professional Sheet including death, when prescribed (www.fda.gov/medwatch/safety/20 for the management of acute 07/safety07.htm#Fentora) pain in patients who are not available to practitioners who opiate tolerant. Prescribers are prescribe, dispense, or administer also cautioned that mcg-to-mcg fentanyl products. Validate each conversions between fentanyl patient’s opiate tolerance before patches and other forms of use and require personnel who fentanyl products, including dispense or administer these ACTIQ (fentanyl transmucosal products to verify that the patient lozenges) or buccal fentanyl meets prescribing criteria. tablets, are not safe. World Health Organization (WHO): Dilute vincristine in a minibag (15) WHO published a drug alert Dilute vincristine and other vinca following the death of a 21-year- alkaloids in a minibag rather than old woman who received a syringe so it looks dissimilar to vincristine via the intrathecal drugs that are given intrathecally. route. At least 55 other cases For more on preventing fatal have been reported worldwide, vincristine errors, view the free and death is a near-certain FDA Patient Safety Video at: outcome when vincristine is www.access administered to the CNS instead data.fda.gov/psn/transcript.cfm? of IV. show=68#7. Lack of standard dosing methods contributes to IV errors (17) A large variety of IV drug Define and standardize adult (and dosing methods exist in if applicable, pediatric) dosing hospitals. For example, the methods to be used for each drug same drug might be administered IV in your administered within the same organization. Employ smart pumps facility using the dosing and program them using the methods of mcg/kg, endorsed dosing method. The dose mcg/kg/min, or mcg/kg/hour on the prescriber's order, the MAR, concentrations. Lack of and the drug label should match standardization makes the dosing method required to recognition of dosing errors program the infusion pump. difficult, even when using smart pumps.

April 19, 2007 ISMP MedicationSafetyAlert! QAA 2 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment IV fluorouracil infused in 4 hours instead of 4 days (19) A patient undergoing treatment Display information needed to for advanced carcinoma program infusion pumps in a received a fatal dose of standard way. The mL/hour rate, fluorouracil, given over 4 hours not the mL/24 hour rate, should be instead of 4 days. Two nurses prominent. Minimize the need for miscalculated the infusion rate, calculations at the bedside. Use forgetting to divide the daily checklists to structure task dose by 24 hours. The pharmacy workflow. Use chemotherapy label listed the mL/24 hour rate certification processes to validate of infusion first, then the that staff possess and maintain an mL/hour rate. The nurses saw appropriate level of skills, the mL/24 hour infusion rate and knowledge, and abilities before thought their erroneous working independently. See the full calculations were correct. Failed article for details at: double-check systems and pump www.ismp.org/ design flaws also contributed to Newsletters/acutecare/archives/Se the error. p07.asp#20. Confusion with SYMLIN (pramlintide acetate) dosing (17) Symlin may be prescribed for Teach patients how to draw up the insulin-dependent diabetic correct dose of Symlin using an patients to enhance glucose insulin syringe, and validate control. It is prescribed in mcg, understanding by observing a not units. Patients may return demonstration. Also validate confuse the "mcg" dose of that the patient knows how to Symlin with the "unit" dose measure doses in general in case markings on the insulin the dose is changed. Instruct the syringes used to administer patient not to mix Symlin and the dose, leading to insulin in the same syringe. potentially serious dosing errors. New ROCEPHIN (ceftriaxone) warning (14) FDA and Roche published an A second advisory advisory about a potential (www.fda.gov/medwatch/ problem when Rocephin is safety/2007/Rocephin_HCP_august used concomitantly with 2007.pdf) stresses that Rocephin calcium or calcium-containing and calcium-containing solutions, products within 48 hours, including parenteral nutrition,

April 19, 2007 ISMP MedicationSafetyAlert! QAA 3 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment especially in neonates. should not be mixed or co- administered within 48 hours to any patient, even via different infusion lines at different sites. Computer alerts or smart pumps can help warn clinicians about such conditions. Insulin CONCENTRATE U-500 (15) With use of U-500 insulin Evaluate how insulin is listed on products in hospitals on the order entry screens; if the rise, reports of mix-ups concentration appears at the far between U-100 and U-500 right of the drug information, the insulin are also increasing. The risk of selecting the wrong product way insulin products are listed increases. Drug information on computerized order-entry vendors have agreed to screens is often a causative incorporate the word factor in erroneously selecting "CONCENTRATED" to U-500 insulin U-500 insulin when entering entries. Consider adding a hard orders. Access to concentrated stop on U-500 insulin orders to insulin on patient care units require prescriber and pharmacist also increases the likelihood of verification before proceeding. an inadvertent overdose. Segregate the storage of these two strengths of insulin. Failure to cap IV tubing and disinfect IV ports place patients at risk (15) Leaving the distal end of IV Organizational policies and tubing uncapped between procedures should detail the intermittent infusions and failing expectations related to to disinfect IV ports on needle- maintenance of aseptic technique free valves before access including disinfection of vascular increases the likelihood that access lines and ports. Teach patients will acquire a these expectations to individuals healthcare-associated infection. who administer medications and Meticulous attention to aseptic conduct rounds on patient care technique including proper units to document baseline disinfection of IV access devices compliance and measure is not the observed norm in improvement. many organizations Preventing mix-ups between various formulations of amphotericin B

April 19, 2007 ISMP MedicationSafetyAlert! QAA 4 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment (18) Several reports of fatal mix- Communicate orders for drugs with ups between conventional and liposomal and conventional forms lipid-based formulations of using both the proprietary and amphotericin B were recently complete generic name (e.g., published in the United AMB-ISOME [amphotericin B Kingdom. Alerts issued by liposomal]). Restrict the ISMP since 1997 have called preparation and dispensing of attention to mix-ups between amphotericin B products to the the lipid-based and pharmacy. Separate the storage of conventional formulations of different formulations. Additional drugs. recommendations can be found at: www.ismp.org/News letters/acutecare/articles/2007090 6_1.asp. BYETTA (exenatide) barcode scanning inconsistencies (16) Two formulations of Byetta are Manual double-checks of Byetta distributed in pen injectors, products are warranted to ensure one delivering 5 mcg/injection the correct strength is dispensed, and one delivering 10 especially in community settings mcg/injection. The wrong where erroneous dispensing could strength may be dispensed lead to repeated dosing errors. because both pens have similar NDC numbers. Only the final digits of the NDC numbers are different, and the barcodes for both products may not include these final digits. Another problem with Byetta (exenatide) (16) A nurse reported administering Review educational processes that the full contents (1.2 mL) of a are used when new products are Byetta prefilled pen to a patient introduced in your organization. Do instead of the intended dose of 5 not assume that all pen injector mcg (0.02 mL), a 60-fold devices operate similarly; evaluate overdose. The nurse saw the the steps necessary to ensure that prescribed dose of 5 mcg on the a dose is delivered successfully pen's label but no directions on and accurately each time a new the pen itself. She missed the product is considered. Ensure that

April 19, 2007 ISMP MedicationSafetyAlert! QAA 5 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment concentration and total volume nurses receive adequate, hands-on listed on the pen in fine print. education with pen injector She'd never used Byetta and was devices before introducing new unsure how to activate it, so she products into patient care areas. withdrew the entire contents from the pen into a separate syringe and administered the full amount to the patient. Potential problem with EXACTACAIN spray (benzocaine 14%, butamben 2%, tetracaine 2%) (14) Some Exactacain applicator Use only the straws packaged with straws have been "popping off each Exactacain container, not into patients' throats." Recent leftover straws from the older product changes to the spray container. Discard leftover straws release button necessitated when starting a new container. For re-sizing applicator straws. more information, view a free FDA Straws for use with the Patient Safety Video on this topic original Exactacain spray at: release button are not www.accessdata.fda.gov/psn/trans compatible with newly cript.cfm?show=68#6. designed spray release button and will pop off during use. Updated: ISMP's List of High-Alert Medications (16) High-alert medications are Based on a 2007 practitioner drugs that bear a heightened survey and review by ISMP and risk of causing significant other medication safety experts, patient harm when used in ISMP's List of High-Alert error. Special safeguards may Medications has been updated reduce the risk of error. (www.ismp.org/Tools/highalertmed ications.pdf). Organizations are strongly encouraged to evaluate the error potential for each high- alert drug, and take proactive measures to reduce risk. Talc given IV (17) A patient died after a talc Drugs used for pleurodesis should suspension was administered IV be delivered to the unit instead of being instilled through a immediately prior to the chest tube during a pleurodesis procedure; they should be

April 19, 2007 ISMP MedicationSafetyAlert! QAA 6 January – March 2007 ISMP QuarterlyActionAgenda No. Problem Recommendation Organization Action Required/ Date Completed Assessment Assignment (causes the membranes around prepared in a catheter-tipped the lung to stick together to syringe (not a parenteral syringe) prevent fluid buildup in the space which is labeled “for chest tube between the membranes). The instillation only." Use a pre- nurse misinterpreted the word "in" procedure "time out" to confirm amid the order for "talc in saline" patient identity, clarify the plan of as "IV." The product was care, and ensure that appropriate dispensed in a parenteral syringe equipment and medications have with "IV additive product" listed on been brought to the bedside. the label.

April 19, 2007 ISMP MedicationSafetyAlert! QAA 7