Volume 25, Issue 8 April 23, 2020

April 23, 2020 Volume 25 Issue 8 SPECIAL EDITION COVID-19

Error-prone dose expression on label of COVID-19 Collaboration unapproved drug, ascorbic acid, from Mylan Tripping on extension tubing PROBLEM : A pharmacist received an order for 500 mg of intravenous (IV) ascorbic A COVID-19 patient was being treated in acid for a patient with coronavirus (COVID-19). Although this product was on an intensive care unit (ICU) in a negative formulary at the hospital, it was rarely used prior to the COVID-19 pandemic, and pressure room. An ICU nurse had seen a the pharmacist had never dispensed it. (In COVID-19 investigational trials, IV ascorbic post on social media about another facility acid is being used in much larger doses placing smart infusion pumps outside of [i.e., 10 or 12 g] after being added to an patient rooms to help minimize the use of appropriate diluent, with the theory that it personal protective equipment (PPE). She will hasten recovery.) decided to implement this workflow. She moved the infusion pump to an anteroom After selecting the available vial of ascorbic outside the patient’s negative pressure acid injection (Mylan), the pharmacist room, and used extension sets to run the noticed that the principal display panel on tubing under the door and to the patient. the carton and vial label indicated that it The patient was receiving intravenous contained 500 mg/mL ( Figure 1 ). This is in (IV) norepinephrine via the infusion pump conflict with USP <7>, which requires most to treat hypotension. The extension tubing medication labels to list the total amount of was on the floor and not secured to drug and volume in the vial (with the per Figure 1. Mylan 50 mL ascorbic acid vial contains prevent a tripping hazard. At some point, mL amount below it in parentheses) on the 25 g/50 mL; however, the carton and vial labels staff tripped on the extension tubing, principal display panel. She initially thought only list 500 mg/mL, failing to note the 25 g total which caused the tubing to become contents anywhere on the labels. the entire vial contained 500 mg. However, disconnected from the patient for an the 50 mL vial contains 25 g (25,000 mg) of ascorbic acid. The Mylan website refers unknown period. Fortunately, no adverse to this product as containing “25 g/50 mL (500 mg/mL),” but neither the carton nor outcomes were reported in the patient. the vial label indicates that the entire vial contains 25 g. The label does note that the vial contains 50 mL, but even this is in small font in the top right corner of the prin - Until this event happened, nursing and cipal display panel (following the NDC number). pharmacy leadership had not planned for this workflow change and did not know In this case, the pharmacist asked a pharmacy technician to that the ICU staff had moved this one prepare the 500 mg dose, which she mistakenly stated would infusion pump to the anteroom. However, require all 50 mL of the product in the vial. However, the the event gave the hospital an opportunity hospital used an information technology system for to review their processes and the infor - compounding that specified to withdraw 1 mL from the vial mation provided by ISMP in our April 3, for the 500 mg dose. Noting the discrepancy between the 2020 newsletter ( Clinical experiences pharmacist’s verbal instructions and the compounding keeping infusion pumps outside the room system instructions, the technician brought the vial back to for COVID-19 patients ; www.ismp.org/ the pharmacist to question how much to withdraw from the node/15321 ), as well as explore the vial. The pharmacist then realized her mistake and that experiences of other facilities. Based on administering the entire vial contents (50 mL, 25 g) would that assessment, the hospital determined have resulted in a 50-fold overdose. that, at this time, the risks outweigh the benefits and decided not to position infu - SAFE PRACTICE RECOMMENDATIONS : If you are preparing sion pumps outside of patient rooms. or administering IV ascorbic acid, please be aware of the Figure 2. FDA-approved ascorbic acid injection from error-prone labeling on the Mylan product and on some McGuff Pharmaceuticals Identifying QT-prolonging drugs other manufacturers’ ascorbic acid injection vials. The US properly designates product The nonprofit Arizona Center for Educa - Food and Drug Administration (FDA) was made aware of concentration as 25,000 mg/ tion and Research on Therapeutics the labeling issue; however, the Mylan product is not FDA- 50 mL ( 500 mg/mL). (AZCERT) has launched a decision sup - approved ( www.ismp.org/ext/453 ). We have learned that Mylan has discontinued port program to help clinicians manage continued on page 2 — Ascorbic acid > continued on page 2 — Collaboration > April 23, 2020 Volume 25 Issue 8 Page 2

COVID-19 Collaboration cont’d from pg 1 > Ascorbic acid — continued from page 1 this unapproved product but some existing product may still be in the marketplace. the risk of QT-prolonging medications If you have Mylan ascorbic acid injection, we recommend affixing an auxiliary label when treating patients with COVID- to the carton and/or vial indicating the total amount of drug in each vial. Pharmacies 19. MedSafety Scan (https://medsafety can purchase ascorbic acid injection vials from other manufacturers that safely scan.org/ ) is available without charge express the total amount of drug in each vial on the label. ASCOR (ascorbic acid) (registration required) to healthcare from McGuff Pharmaceuticals is an FDA-approved product that lists the total amount professionals treating COVID-19 patients. (25,000 mg) contained in each 50 mL vial ( Figure 2 , page 1). The program reports if any of the patient’s prescribed medications are in the QTdrugs database from the CredibleMeds Highlights of a COCA webinar on insights from website ( www.crediblemeds.org ), calcu - two health systems impacted by COVID-19 lates the patient’s QT-risk score for QT prolongation and torsades de pointes, and n April 17, 2020, the Clinician Outreach and Communication Activity (COCA) screens for major drug-drug interactions presented a webinar, COVID-19 in the United States: Insights from and contraindicated drug pairs. Avoiding OHealthcare Systems . COCA, the Centers for Disease Control and Prevention any non-essential QT-prolonging drugs (CDC) emergency preparedness and response resource, helps prepare clinicians to and implementing electrocardiograph respond to emerging health threats and public health emergencies by communi - (ECG) monitoring of patients who must cating relevant, timely information. This webinar, the latest in a series of a dozen take these medications is highly recom - COCA webinars associated with COVID-19, provides an overview of key challenges mended. AZCERT maintains Credible- and successes of the pandemic from the perspective of two profoundly impacted Meds, an excellent resource for the safe health systems, Mount Sinai Health System in NY and Providence in WA (and other use of medications, with a special focus states). If you were unable to attend the webinar last Friday, you can still access a on drugs that increase the risk of torsades recording of it at: www.ismp.org/ext/452 . A summary highlighting some of the de pointes. CredibleMeds received an interesting points raised during the webinar follows. ISMP CHEERS AWARD in 2015.

CDC Decontamination of N95 respirators Dr. Aaron Harris from the CDC opened the webinar with the latest statistics about The preprint (not yet peer reviewed) the pandemic in the US, stating that health systems throughout the country are in results of a National Institutes of Health various phases of the crisis, ranging from pre-crisis to the beginning signs of (NIH) study on decontamination of N95 de-escalation. However, he notes that all health systems need to prepare for the respirators to facilitate reuse during a pandemic, stressing that those that have excelled at meeting the challenges had critical shortage were posted on April emergency plans in place before the surge of COVID-19 patients. 15, 2020 ( www.ismp.org/ext/451 ). The study analyzed four decontamination AHA methods—UV radiation (260 – 285 nm), Nancy Foster from the American Hospital Association (AHA) remarked that, while 70º C dry heat, 70% ethanol, and vapor - the resources, technology, and infrastructure of US health systems are highly variable, ized hydrogen peroxide (VHP)—for their we can all learn from the experiences of others and apply the lessons learned to our ability to reduce contamination with the own health system. She described the unique challenges experienced by all health SARS-CoV-2 virus and maintain N95 systems, including financial and human resource limitations, loss of community respirator integrity, particularly filtration trust, and lack of a unified response for health systems that cross state lines. performance and fit scores. The data indicate that VHP treatment exhibits the Mount Sinai best combination of rapid virus inactiva - Dr. David Reich from the Mount Sinai Health System, which is beginning to see a tion and preservation of N95 respirator downward trend in COVID-19 patient bed occupancy, shared details about how the integrity, allowing reuse for up to three system was able to conserve personal protective equipment (PPE) by initially reserving times. UV radiation kills the virus more N95 respirators primarily for aerosol-generating procedures and limiting extended slowly but also preserves N95 respirator use of PPE to designated units. In these designated units, red, yellow, and green tape function, again allowing reuse for up to is used to create zone markers to differentiate hot, intermediate, and clean zones. three times. Dry heat (70º C) kills the virus with similar speed and is likely to main - To support staff, the leaders arranged food donations and created sleeping arrange - tain acceptable fit scores for two rounds ments, respite stations, and crisis hotlines. To support communication, daily briefings of decontamination. Ethanol decontami - with senior leaders, twice daily huddles with local leadership, twice daily calls with nation is not recommended due to loss union bargaining units, daily leadership “elbow bump” rounds with frontline staff, of N95 respirator integrity. and weekly virtual town halls are held. To increase the workforce, clinical staff were redeployed, leaving behind their preexisting titles to become an integral part of a The authors stress that utmost care should hospitalist team. One lesson learned: when two key leaders in one hospital became be taken to ensure the proper functioning continued on page 3 — COCA webinar > continued on page 3 — Collaboration >

© 2020 ISMP. Reproduction of the newsletter or its content for use outside your facility, including republication of articles/excerpts or posting on a public-access website, is prohibited without written permission from ISMP. April 23, 2020 Volume 25 Issue 8 Page 3

COVID-19 Collaboration cont’d from pg 2 > COCA webinar — continued from page 2 ill, the health system found it necessary to redeploy an entire leadership team, and of the N95 respirator after each decont - not just replace the two leaders, to help the hospital run smoothly during the amination using available fit test tools. pandemic. They also note that treatments must be carried out for sufficient time (particularly The health system expanded critical care capacity by transitioning 10 adult units to for UV and dry heat) to achieve the 240 adult intensive care unit (ICU) beds, sometimes placing two patients in a single desired risk-reduction. The authors ICU room. The system also converted 260 patient rooms to negative pressure rooms suggest that the study’s estimated decay using high-efficiency particulate air (HEPA) exhaust fans. Non-traditional ventilators rates together with estimates of the (e.g., anesthesia machines, transport ventilators, specialty ventilators) were incor - degree of real-world contamination can porated to maximize capacity. The health system also set up a 68-bed emergency be used to choose appropriate treatment field hospital in tents in Central Park, staffed by Samaritan’s Purse physicians and durations. Additional studies about N95 nurses who are caring for dozens of COVID-19 patients. respirator decontamination and reuse can be found at: www.ismp.org/ext/456 . The health system has recently developed the capacity for in-house testing of workers and patients, allowing for high-volume testing of all staff and patients as of Warn patients not to take ivermectin last week, as well as remote patient monitoring and point-of-care testing. They also for animals developed a convalescent plasma program, including protocols for plasma donation, On April 10, 2020, the US Food and Drug patient selection, consent and enrollment, transfusion, and monitoring. COVID-19 Administration (FDA) issued a medical treatment protocols and clinical trials for each level of infection (e.g., moderate, product safety alert about a concern that severe, critical, multi-system organ dysfunction) have been implemented, as well as consumers may take ivermectin products an anticoagulation protocol to address thromboprophylaxis in COVID-19 patients. intended for animals, thinking they can cure COVID-19 ( www.ismp.org/ext/454 ). Providence After an ePub research article document - Dr. Amy Compton-Phillips from Providence, which treated the first US hospitalized ing how ivermectin inhibits the replication COVID-19 patient in January, stressed the need for planning to stay ahead of the of the SARS-CoV-2 virus in a petri dish (Caly curve. She described how the health system was able to create a robust epidemic L, Druce JD, Catton MG, Jans DA, wagstaff registry and then use the data about patients, staff, locations of care, products, and KM. The FDA-approved drug ivermectin capacity triggers to support surveillance and planning. She also noted that an emer - inhibits replication of SARS-CoV-2 in gency command center was provided with nightly reports to guide leadership vitro . Antiviral Res . 2020 ; 178:104787; decisions. www.ismp.org/ext/450 ) was published, the FDA’s Center for Veterinary Medicine The health system was able to tap into an existing telemedicine platform to ramp became aware of increased public up telehealth services, including a chatbot-assessment of symptoms for consumers, visibility of this medication. Ivermectin acute care and triage telehealth services using experienced telehospitalists, and tablets are approved for human use for drive-through testing. The system’s telehealth encounters skyrocketed from 70,000 the treatment of some parasitic worms, visits per year to 70,000 visits per week. The system has also sent self-monitoring and topical formulations are approved tools (e.g., pulse oximetry unit, thermometer) to patients, primarily to keep at-risk for human use for the treatment of head patients at home. lice and skin conditions such as rosacea. But in the latest study, no ivermectin was Dr. Compton-Phillips reinforced Dr. Reich’s description of the need for leadership administered to humans. Additional communication with the frontline workers. The leaders at Providence maintain a testing is needed to determine whether regular cadence of huddles with the emergency operations group each morning, ivermectin might be appropriate to daily regional and system huddles, and daily walk-arounds. Because leaders both prevent or treat COVID-19. Please warn talk and listen to frontline workers, the two-way communication has been a flotsam patients that they should never take any for staff to hold onto in this storm. form of ivermectin, including ivermectin for animals, unless it has been prescribed Dr. Compton-Phillips also described how the system’s emergency departments (EDs) by a healthcare provider and is obtained are currently running at about 50% capacity because patients are afraid of contracting through a legitimate source. Medications COVID-19 and thus deferring treatment for both acute and chronic conditions. She for animals can cause serious harm in noted that, unfortunately, heart attack and stroke patients are waiting to seek treat - people. ment, often arriving in the ED too late to administer thrombolytic therapy. She shared the story of an elderly man who lost vision in one of his eyes and waited 3 Please help FDA protect public health by days before calling his daughter. By the time he arrived in the ED for assessment alerting the Agency to anyone claiming and treatment, he had suffered a completed stroke. The health system is now to have a product to prevent or cure planning for the surge of patients who deferred care during the pandemic, as well COVID-19. Send an email to FDA-COVID- as anticipating new patient groups that might need care, including additional waves [email protected] or of COVID-19 outbreaks. call 1-888-InfoFDA (1-888-463-6332). continued on page 4 — COCA webinar > continued on page 4 — Collaboration > April 23, 2020 Volume 25 Issue 8 Page 4

COVID-19 Collaboration cont’d from pg 3 > COCA webinar — continued from page 3 The health system is using its COVID-19 response as an opportunity to learn from FDA management of drug shortages the past and re-imagine their role in the future. The system is considering far-reaching The US Food and Drug Administration changes ranging from modifications in the reimbursement system to further use of (FDA) has issued a guidance to manufac - the technology tools, including telemedicine, that helped get them through the crisis. turers ( www.ismp.org/ext/395 ) to help them provide the agency with timely and Mount Sinai and Providence are willing to share their processes and tools associated informative notifications about changes with COVID-19, so if you have questions or inquiries, please reach out via email to: in the production of certain drugs and [email protected] and/or [email protected] . biological products. FDA has been closely monitoring the medical product supply chain with the expectation that it may be Worth visiting... impacted by the pandemic, potentially leading to drug shortages. In urging the timely submission of notifications, the American Diabetes Association (ADA)—Town Hall: Inpatient Care for People with guidance may assist the FDA in its efforts Diabetes & COVID-19 (www.ismp.org/ext/434 ) to prevent or mitigate shortages of such products, including under circumstances The ADA has posted a free webinar on the hospital management of patients with both outside of the COVID-19 pandemic. diabetes and COVID-19. The webinar presents a panel of experts who provide in-depth opinions about the complex management of these patients, from insulin therapy for both type 1 and type 2 diabetes, to the management of hyperglycemia and ketoacidosis. The panel also provides expert advice about treatment in patients with insulin resistance, comorbid conditions (e.g., obesity, renal insufficiency, underlying pulmonary and cardiac Public survey on COVID-19 symptoms disease), as well as those undergoing a cytokine storm brought on by COVID-19. The Regenstrief Institute, a research organization driven by a mission to American Society of Health-System Pharmacists (ASHP)—Field/Surge Hospital and connect and innovate for better health, is ICU Bed Expansion Responses to COVID-19 (www.ismp.org/ext/435 ) conducting a 3-minute public survey to track the coronavirus and understand who Early in April, ASHP published responses to questions related to preparing for field and might be experiencing symptoms. Your surge hospitals, including establishing new ICU beds, staffing needs, use of automation assistance will help medical communities and electronic health records (EHRs), as well as other advice and considerations. One better monitor trends in symptoms and of the questions relates to how hospitals are assessing historic drug use for allocation guide the official response in key regions. in the new field/surge hospital(s). This information was collected during the last week The Institute may share the survey findings in March from practice sites across the country, including NY and wA. From new with the general public through scientific supplier agreements to plans for sterile compounding support, this resource provides publications, collaborations with other important information (now available to non-members) for hospitals considering their scientists, and postings on various news options for overflow patients. organization websites. To take the survey, visit: www.ismp.org/ext/436 . Wolters Kluwer—COVID-19 Resources & Tools (www.ismp.org/ext/437 ) To subscribe: www.ismp.org/node/10 wolters Kluwer is making various COVID-19 updates and resources available at no charge. This includes free access to UpToDate , podcasts, Emmi videos, both patient ISMP Medication Safety and healthcare provider resources from journals published by wolters Kluwer and Alert! Acute Care (ISSN 1550-6312) © 2020 Institute Lippincott, as well as curated resources and tools available through Ovid. for Safe Medication Practices (ISMP). Subscribers are granted permission to redistribute Medscape—COVID-19 Clinical Guidelines (www.ismp.org/ext/448 ) the newsletter or reproduce its contents within their prac - tice site or facility only. Other reproduction, including post - ing on a public-access website, is prohibited without written Medscape has compiled more than a dozen 2020 COVID-19 clinical practice guidelines permission from ISMP. This is a peer reviewed publication. from various national and international professional organizations. Examples include: Report medication and vaccine errors to ISMP: preparing the workplace for COVID-19, from the Occupational Safety and Health Please call 1-800-FAIL-SAF(E), or visit our website at: Administration (OSHA); surgical triage of patients with breast cancer, from the COVID-19 www.ismp.org/MERP or www.ismp.org/VERP . ISMP guarantees the confidentiality of information received and Pandemic Breast Cancer Consortium (CPBCC); performing procedures on patients with respects the reporters’ wishes regarding the level of detail known or suspected COVID-19, from the American Society of Anesthesiologists (ASA); included in publications. COVID-19 ventilation clinical practice guidelines, from the European Society of Intensive Editors: Judy Smetzer, BSN, RN, FISMP; Michael Cohen, Care Medicine (ESICM) and the Society of Critical Care Medicine (SCCM); and the RPh, MS, ScD (hon), DPS (hon), FASHP; Ann Shastay, management of COVID-19 infection during pregnancy, childbirth, and the neonatal period, MSN, RN, AOCN; Russell Jenkins, MD; Ronald S. Litman, DO, ML. ISMP, 200 Lakeside Drive, Suite 200, Horsham, from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). PA 19044. Email: [email protected] ; Tel: 215-947-7797; Fax: 215-914-1492.

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©2020 ISMP January - March 2020 ISMP Action Agenda Issue Problem Recommendation Organization Assessment Action Required/Assignment Date No. Completed Two new Best Practices in the 2020-2021 Targeted Medication Safety Best Practices (TMSBPs) for Hospitals (4) The TMSBPs ( www.ismp.org/node/160 ) ISMP encourages hospitals to implement consist of 16 Best Practices, including 2 the two new Best Practices as well as new practice s: #15) Verify and document the older ones. Helpful accompanying a patient’s opioid status prior to prescrib - resources include the TMSBPs ing and dispensing certain opioids; and Frequently Asked Questions (FAQs) #16) a. Limit the variety of medications (www.ismp.org/node/14369 ) and an removed via override from an automated Implementation Worksheet ( www.ismp. dispensing cabinet (ADC); b. Require an org/node/1506 ). Also, please take our order before removing a medication from survey ( www.ismp.org/ext/350 ) on base - an ADC; c. Monitor ADC overrides; and line implementation of the two new prac - d. Periodically review the medications tices so we can measure improvement available via override. over time. Smart infusion pumps with dose error-reduction systems (DERS) should be used in the operating room (OR) (5) Use of smart infusion pumps with DERS Make use of smart pumps with DERS an in the OR by anesthesia providers is expectation in the OR. Engage anesthesia

I thesia providers use smart pumps with library, implement upper and lower hard S M P DERS, data can be analyzed to improve dose limits, and restrict the use of pumps safety. A recent analysis from anesthe - in anesthesia mode. Require use of the sia providers using smart pumps bolus feature (with hard limits for cata - showed frequent programming of strophic doses), and do not allow the propofol and dexmedetomidine in delivery of bolus doses by increasing the excess (3- to 4-fold greater) of labeled rate of infusion. Train anesthesia providers dosing for an hour or more. These dose to use smart pumps with DERS, including excursions were likely caused by not the bolus dose feature. Analyze pump using the pump’s bolus dose feature and data to understand and improve practice. lack of hard stops when using pumps in Also see the ISMP guidelines on smart anesthesia mode. infusion pumps: www.ismp.org/node/972 . Containers with dual linear barcodes lead to scanning the wrong barcode (3) Some intravenous (IV) products, such as If pharmacies are not using the lot number ce FAZolin Duplex containers (B. Braun), and expiration date linear barcode, com - have two linear barcodes: one for the pletely block out that barcode before dis - lot number/expiration date, and the other pensing to help ensure nurses use the for the national drug code (NDC). If a correct barcode to scan for product iden - nurse scans (or the scanner “reads”) tification. We have contacted B. Braun to the barcode with the lot number/expira - suggest replacing the lot number/expira - tion date, the unsuccessful scan can tion date linear barcode with a 2D bar - lead to a delay and calls to the phar macy. code that also includes the NDC num ber.

April 23, 2020 ISMP Medication Safety Alert! Acute Care AA 2 January - March 2020 ISMP Action Agenda Issue Problem Recommendation Organization Assessment Action Required/Assignment Date No. Completed Unsafe expression of strength on Teva vials of haloperidol decanoate injection (3) An automated dispensing cabinet (ADC) If a 250 mg vial is needed, purchase it was almost refilled with 5 mL vials of from a different manufacturer until Teva haloperidol decanoate injection product labeling is updated using the (50 mg/mL) instead of 1 mL vials. Both proper format for listing the concentra - the 5 mL vial and outer carton labels tion. Also ensure that barcode scanning list the strength per mL (50 mg/mL) of the product occurs when the ADC is rather than prominently noting the refilled. total amount per vial (250 mg/5 mL), as required in USP <7>. Waste and error risk tied to packaging of STIVARGA (regorafenib), an antineoplastic agent (2) Stivarga comes in a carton containing To prevent patients from taking extra three 28-count bottles of 40 mg tablets when prescribed lower doses, tablets, which are needed for the teach patients that there is more recommended dose of 160 mg daily medication than needed and instruct for 21 days of a 28-day cycle. How - them on what to do with the leftover ©

2 ever, reduced dosing (120 mg or 80 medication. Provide patients with a 0 2 0

I S mg daily) may be required. Since dosing calendar for the 4-week cycle M P tablets must be stored in the original that blocks off the final 7 days, when bottle, some pharmacies dispense the no medicine should be taken. Patient full carton, which can lead to leftover education material is available from tablets, waste, taking extra doses, and Bayer at: www.ismp.org/ext/337 . improper insurance billing.

Methadone overdose linked to errors in prescribing, dispensing, and administering the drug (4) When prescribing methadone oral Order entry systems should default to solution 2.5 mg twice daily, a physician the most appropriate concentration selected a concentrated solution of the product based on the patient’s (10 mg/mL) rather than a 1 mg/mL solu - dose. Pharmacy-prepared oral syringes tion. Not recognizing that only 0.25 mL that contain patient-specific doses would be needed for each dose, a should be dispensed for high-alert pharmacist dispensed a batched oral medications; one syringe should equal syringe (60 mg/6 mL). Instead of scan - one dose. If products must be batched, ning the patient-specific barcode on the a single, patient-specific barcode syringe, the nurse scanned the barcode should be available for nurses to scan on the outer bag, which failed to warn at the bedside. If using batched her to administer only 0.25 mL. The nurse products, standardize doses to match administered the entire 6 mL (60 mg), as commonly prescribed doses in your did an evening nurse. facility .

April 23, 2020 ISMP Medication Safety Alert! Acute Care AA 3 January - March 2020 ISMP Action Agenda Issue Problem Recommendation Organization Assessment Action Required/Assignment Date No. Completed Auxiliary label obscures critical reconstitution information on REVATIO (sildenafil) oral suspension carton label (4) An oral suspension of Revatio requires a Do not obscure important information total of 90 mL of water for reconstitution; with auxiliary labels, price stickers, or 60 mL followed by an additional 30 mL. other labels that are affixed to medication A pharmacy technician missed adding cartons or containers. Make sure recon - the 30 mL aliquot because an auxiliary stitution instructions are clearly visible. label placed on the carton obscured part of the instructions. The reconstitution instructions do not appear on the med - ication’s immediate container. Generic insulin pen (70% insulin aspart protamin e/3 0% insulin aspart) needs to be relabeled (5) A new generic insulin pen for the Relabel or add an auxiliary label to note NOVOLOG MIX 70/30 FlexPen does not the ratio expression and to note that each specify the insulin ratio on the syringe or 100 units contains 70 units of insulin aspart carton, unlike the brand product. The protamine and 30 units of insulin aspart. 70/30 ratio is only in the package insert. ISMP has recommended label redesign © 2

0 A 10 mL vial of the generic insulin also to both the US Food and Drug Adminis - 2 0

I S does n ot list the 70/30 ratio on the label. tration (FDA) and the manufac turer. M P Top 10 medication errors and hazards in 2019 (1) ISMP’s top 10 medication errors and These issues warrant your attention and hazards in 2019 included: 1) selecting priority given the serious consequences the wrong medication from a computer of an error. Review the list of errors and screen; 2) daily instead of weekly oral hazards in detail and implement the methotrexate; 3) look-alike product recommended actions to mitigate labeling; 4) misheard verbal orders; these risks ( www.ismp.org/node/ 5) unsafe automated dispensing cabinet 13939 ). Include strategies to prevent overrides; 6) unsafe IV push practices; these errors and hazards in your 2020 7) intraspinal tranexamic acid; 8) unsafe strategic medication safety improve - 503b compounder labeling; 9) use of ment plan. syringes for vinca alkaloids; and 10) 1,000- fold zinc overdoses. Nizatidine confused with tiZANidine (1) A recall of ranitidine led a hospital to Alert practitioners to the risk of confusion substitute it with nizatidine. Shortly between nizatidine and ti ZANidine . thereafter, nizatidine was mistakenly Use tall man letters when expressing prescribed instead of ti ZANidine. Both ti ZANidine . Reduce possible dispensing drugs have similar letters, with the last and administration errors by using bar - 5 letters (-idine) overlapping exactly. code scanning during product se lection.

April 23, 2020 ISMP Medication Safety Alert! Acute Care AA 4