Oral Medications Inadvertently Given Via the Intravenous Route

REVIEWS & ANALYSES

Oral Medications Inadvertently Given via the Intravenous Route

Ali-Reza Shah-Mohammadi, PharmD, MS INTRODUCTION Patient Safety Analyst Inadvertent intravenous (IV) administration of oral medications is a subset of medi- Michael J. Gaunt, PharmD Senior Patient Safety Analyst cation administration errors. These errors occur most often when an oral liquid is Pennsylvania Patient Safety Authority prepared or dispensed in a parenteral syringe. According to the Institute for Safe Medication Practices (ISMP), a break in mental concentration can subsequently lead to the oral medication being unintentionally administered through the IV route. 1 ABSTRACT Wrong-route errors at the time of administration have become an important issue in 2 The inadvertent intravenous (IV) admin- hospitals. This also is of major interest to patients due to the central role medications istration of oral medications, while have in treating illnesses, as well as the important consequences to the patient if this is 2 rarely reported, has contributed to done incorrectly. Medication administration is a critical step because an error that is serious patient harm, as seen in event not caught will always reach and possibly harm the patient, and there may be limited 3 reports submitted to the Pennsylvania options for corrective actions. Patient Safety Authority and in the While any route of administration can be involved in medication errors, patients clinical literature. Analysts identified receiving IV medications are at particular risk.4 More importantly, medication admin- 20 reports of inadvertent IV adminis- istration errors tend to occur frequently and are more likely to result in serious harm tration of oral medications submitted and death in comparison with other types of medication errors.5 Also, certain types to the Authority between June 2004 of errors, including wrong-route errors, are more likely to result in patient harm com- and December 2012. All of the events pared with other error types, even though they may occur less often relative to other reached the patient, and 20% (n = 4) errors.6 For example, infusion of nonsterile, particulate fluid can be fatal, as it carries resulted in patient harm, including one the risk of sepsis, diffuse intravascular coagulation, or emboli to major organs, which death. A common contributing factor can lead to organ damage and pulmonary embolism. There are published studies that cited in many of these reports was that address certain medications, including oral medications, mistakenly given via the IV the oral drug was administered using route .7-15 This analysis focuses on events involving oral medications inadvertently given a parenteral syringe. While the clinical intravenously. literature on these errors predominantly addresses the administration phase of METHODS the medication-use process, events and A query was conducted of the Pennsylvania Patient Safety Reporting System (PA-PSRS) decisions that precede administration database for reports of inadvertent IV administration of oral medications submitted may play a role. Avoiding these types between June 2004 and December 2012. Analysts queried the database for the term of errors requires more than one error “oral” among the report fields for “medication prescribed route,” “medication admin- reduction strategy. Strategies to mitigate istered route,” and “event detail” within medication error events that were classified such errors may include assessing the by facilities as wrong-route errors. Analysts also queried for specific oral medications current medical devices within the facil- (e.g., niMODipine, morphine) identified during ongoing event analysis as having been ity to understand key system factors inadvertently administered intravenously. Analysts manually reviewed the event reports playing a role in this type of medication to determine whether there was an instance of an oral medication inadvertently given error; dispensing oral medications in intravenously. Of the initial 1,995 event reports, 20 had some description of an oral the most ready-to-use forms; commu- medication that was mistakenly administered intravenously. nicating patients’ inability to swallow capsules or tablets to the pharmacy department; and improving healthcare ANALYSIS professionals’ awareness of such medi- The Table displays the medications involved in the 20 events submitted by facilities. All cation errors. (Pa Patient Saf Advis 2013 20 events reached patients, with 20% (n = 4) resulting in some degree of harm, includ- Sep;10[3]:85-91.) ing death. The medications involved in the events with patient harm were megestrol Corresponding Author acetate, morphine, NIFEdipine, and niMODipine. Michael J. Gaunt Reports submitted to the Authority included terms such as “IV push” to describe the inadvertent IV administration of oral liquid medications. This implies that a parenteral syringe or other device with a needleless (e.g., Luer, Clave) connector was used to administer the medication. The use of parenteral syringes to prepare and administer oral liquid medications is a common contributing factor to these types of

Table. Oral Medications Inadvertently Administered Intravenously, as Reported to the Penn- The patient was confused about the sylvania Patient Safety Authority between June 2004 and December 2012 (N = 20) route of administration and informed the nursing staff and physicians. The MEDICATION NO. OF EVENTS % OF TOTAL REPORTS department of pharmacy was con- Acetylcysteine 5 25 tacted, and the patient had not had niMODipine 3 15 any adverse reactions. Patient was HYDROmorphone 2 10 discharged home with precautions. Acetylcholine chloride 1 5 Upon retrieving the patient’s medication from the automated dispensing Furosemide 1 5 cabinet, the nurse decided to instead Levothyroxine 1 5 override the medication to be admin- LORazepam 1 5 istered and not follow the procedure Medium-chain triglyceride oil 1 5 for wastage. All types of morphine sulfate appeared where the 2 mg/mL Megestrol acetate 1 5 oral solution appeared at the top Morphine 1 5 of the list. The nurse was not sure NIFEdipine 1 5 how to get the medication out of the oxyCODONE 1 5 bottle and asked another nurse for guidance. This other nurse said to Pantoprazole 1 5 just “get a syringe and draw up one milliliter” as she left the patient’s events.1 Using parenteral syringes that niMODipine continues to occur despite room. As the original nurse was can be attached to a needleless IV system a history of product labeling changes, administering the medication, she to administer oral (and enteral) liquids including a boxed warning to alert prac- noticed that the medication was blue. presents a serious danger of misadminis- titioners not to administer niMODipine Upon returning back to the patient’s tration. After filling a parenteral syringe intravenously or by other parenteral room, the other nurse asked the first with an oral or enteral medication, it routes and literature providing risk reduc- nurse if she had to mix the medica- takes only a momentary mental lapse to tion strategies to avoid these errors.10,11,13 tion. The first nurse responded that connect it to an IV line and inject it.16 A case reported to the Authority involving she did not have to mix it since she Reasons why parenteral syringes are used the death of a patient from the inadver- gave it intravenously. The other nurse may include unavailability of patient- tent IV administration of niMODipine is was under the impression that the specific doses in labeled oral syringes as follows: first nurse was giving the medication orally when they realized that the oral prepared and delivered by pharmacy, oral The patient had been receiving syringes not being available in patient care medication was inadvertently admin- medication since admission. A few istered intravenously. areas for nursing staff to use, and staff days after the patient was admit- ® not being aware or not understanding ted, a nurse prepared the patient’s A patient was to receive Protonix the error prevention reasons for using medication via a syringe to be given [pantoprazole] IV and 12 mL of ® oral syringes to administer oral liquid via OGT [an orogastric tube]. At the Mucomyst [acetylcysteine] through medications. bedside, the medication was instead their PEG [percutaneous endoscopic In 2010, the US Food and Drug Admin- administered through the central line. gastrostomy] tube. The nurse drew istration (FDA) alerted healthcare The patient went into asystole and up the Protonix in a 10 mL syringe professionals about the dangers of the expired despite resuscitative measures. and 10 mL of the Mucomyst in a 10 mL syringe. The nurse mixed up IV administration of the contents of Further instances of errors involving other 11 the syringes and gave the Mucomyst niMODipine capsules. FDA identified medications include the following: 31 cases of medication errors, includ- through the patient’s PICC [peripher- ing 4 deaths, associated with the use of A new nurse on the floor was ally inserted central catheter] line. niMODipine between 1989 and 2009.11 unfamiliar with the route of adminis- The physician was on the floor and When reviewing event reports submitted tration for liquid oxyCODONE. As was notified immediately. The charge to the Authority, analysts identified that a result, she gave it in the patient’s nurse notified the pharmacy of the inadvertent IV administration of oral IV [line] instead of PO [by mouth]. incident.

Page 86 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority In addition to not providing details on called away, leaving the nursing student individual. Directing the individual to “be contributing factors to events, many event alone. While the nurse was gone, the more careful” or “pay more attention next reports also did not include descriptions nursing student inadvertently adminis- time” are low-leverage error prevention of patient outcomes. Although it may be tered the drugs intravenously, believing strategies. Rather, facilities may consider assumed that some patients recovered the child was not to consume anything by higher-leverage strategies to minimize the fully prior to discharge, we do not know mouth before surgery. The child remained occurrence of these errors. the overall outcomes of the patients. unconscious for 50 minutes and required ISMP has been a key proponent of several days of antibiotics. The child recov- standardizing drug concentrations, OTHER CASES FROM THE ered fully. maintaining safe and secure storage of LITERATURE Not all cases result in full recovery of medications, and ensuring appropri- Medication errors involving oral medica- the patient. During a holiday weekend, ate distribution of medications and tions inadvertently given intravenously a 19-month-old child was to receive devices to patient care areas. One of its have been published in the literature.7-15 treatment for a chronic gastrointestinal recommended strategies to help mitigate Healthcare settings involved with such disorder.14 The child died after a suspen- inadvertent IV administration of oral errors include hospitals (e.g., critical care sion of cholestyramine was accidentally medications is to use drug products that units, pediatric hematology-oncology administered via a central-line IV catheter are commercially available in ready-to-use units), surgery centers, and pediatric care instead of through an enteral feeding forms.12 While not all medications are centers. The use of a parenteral syringe to tube. A case in Spain claimed the life of commercially available in ready-to-use prepare and administer doses of oral medi- a premature infant.12 The baby was deliv- liquid forms, there have been strides made cations is a common factor in these events. ered via cesarean section one day before to address this issue with certain products. his 20-year-old mother died from the In the second quarter of 2013, Arbor Phar- One case mentioned in the literature swine flu. A week later, the infant died maceuticals announced FDA approval of involved a 14-month-old female with after an intermittent feeding prepared in a a new oral niMODipine solution to help acute lymphoblastic leukemia who was parenteral syringe was administered intra- reduce the medication errors seen with admitted with febrile neutropenia.8 She venously instead of via a nasogastric tube. inadvertent IV administration of the con- was receiving antibiotics through a central tents of oral niMODipine capsules.15 venous catheter, but a nasogastric tube These errors also exact a financial toll on was also placed for enteral feeding. A practitioners and facilities. According to While the healthcare system is making nursing student, under supervision of a two analyses of paid liability claims from advancements in decreasing opportuni- nurse, prepared the patient’s oral medica- 1997 to 2007 17 and 2006 to 2010,18 CNA ties for administration of drugs via the tion with sterile water for injection while Insurance Companies and the Nurses incorrect route, healthcare profession- using a parenteral syringe to administer Service Organization found that claims als can still be diligent to reduce such the oral medication. The nursing stu- alleging wrong medication route, similar errors. Institutions can strongly consider dent, who was left alone at the bedside to those described above, had average paid providing and using oral syringes, versus of the patient, was instructed to inject indemnities of $214,250 (1997 to 2007) parenteral syringes, for administration the oral medication into the nasogastric and $87,500 (2006 to 2010) per claim. of oral medications. By readily providing tube. Unfortunately, the medication was One claim involved a nurse who floated these devices in patient care areas, edu- administered into the central venous line. to the neurology floor, where she was cating staff regarding their purpose, and Another student witnessed this event and instructed to give a 19-year-old man recov- monitoring utilization of oral syringes, informed the physician. To prevent infec- ering from a frontal craniotomy a dose of facilities can help prevent some of the tion, IV antibiotics were given, and the Dilantin® (phenytoin) oral elixir through aforementioned errors. Following are patient was monitored for a short period the patient’s feeding tube.17 The nurse additional strategies that facilities may with no resulting complications. mistakenly gave the drug through the consider to prevent the inadvertent IV patient’s triple-lumen catheter. The patient administration of oral medications: In another case, midazolam syrup and coded within seconds, resulting in a severe acetaminophen liquid were prepared in — Assess, through failure mode and nonrecoverable anoxic brain injury. a parenteral syringe and subsequently effects analysis (FMEA), the pro- administered intravenously to an 11-year- cesses and medical equipment used RISK REDUCTION STRATEGIES old child being prepared for surgery.12 within the facility to understand key A nurse and fourth-year nursing student When reviewing these errors, it is com- factors playing a role in this type of had prepared the doses, but the nurse was mon to lay responsibility onto one medication error. This will allow

users to determine the risks and “Questions to Consider during are incompatible with oral syringes issues leading to oral medications Failure Mode and Effects Analysis of and enteral devices.12,19 One strategy inadvertently being administered Potential Wrong-Route Errors Involv- to accomplish this is to purchase a intravenously. Potential contribu- ing Oral Medications.” different system of medical devices tors to such errors can be revealed — Purchase medication administration (e.g., medication administration through the FMEA process. Sug- equipment and systems that have pumps and associated supplies) for gested questions to ask during the parenteral tubing with ports that each route so that they cannot be FMEA process can be found in physically connected with devices

QUESTIONS TO CONSIDER DURING FAILURE MODE AND EFFECTS ANALYSIS OF POTENTIAL WRONG-ROUTE ERRORS INVOLVING ORAL MEDICATIONS

Failure mode and effects analysis (FMEA) is a tool that can be (i.e., they do not have female Luer connectors)? (Exception: used to evaluate processes, medications, and medical equip- A Luer connector may be used for the inflation balloon that ment used within the facility to identify potential factors and anchors some long-term-use feeding devices.) breakdowns that can lead to medication errors. Facilities can — Who procures specially designed oral syringes for use use FMEA to determine the risks and issues leading to oral within the facility? medications inadvertently being administered intravenously. Grouped according to the applicable key elements from the Staff Competency and Education Institute for Safe Medication Practices’ Key Elements of the — Is the availability and storage location of oral syringes Medication Use System™,1 the following are some questions to shared with all practitioners? consider when performing an FMEA. — Are practitioners taught how and when oral syringes are to Drug Standardization, Storage, and Distribution be used? — Does pharmacy use oral syringes to prepare and dispense — Are practitioners taught th e safety reasons and importance doses of oral liquid medications? of using oral syringes to prevent medication errors? — — Does pharmacy prepare and dispense oral liquid medica- Is this education provided upon hire and reinforced on an tions in labeled, ready-to-use, patient-specific doses? ongoing basis? — Is the oral formulation of the medication packaged by the — Do practitioners receive ongoing information about medi- manufacturer in a vial that looks like a vial typically used cation errors occurring within the organization, error-prone for an injectable product (e.g., acetylcysteine)? conditions, errors occurring in other healthcare facilities, and strategies to prevent such errors? Medication Device Acquisition, Use, and Monitoring Quality Processes and Risk Management — Does the facility purchase specially designed oral syringes that cannot be connected to parenteral tubing for prepara- — Is the use of oral syringes in pharmacy to prepare patient- tion and administration of oral liquid medications that are specific doses of oral medications continually monitored not available in commercially prepared unit-dose cups? and assessed? — — Are oral syringes available in the pharmacy for preparation Is the use of oral syringes to administer oral liquid medi- and dispensing of oral liquid medications? cations in patient care areas continually monitored and assessed? — Are oral syringes available and readily accessible in all patient care areas for use by nurses and other practitioners? — What procedures are in place to identify and manage the risk of errors when an alternative product is introduced to — Are the oral syringes visually different from parenteral and clinical areas? (Note: This applies to newly approved prod- other syringes used within the facility? ucts as well as those brought into the facility in response to — Are the oral syringes prominently labeled by the manufac- drug shortages.) turer with a warning statement similar to “Oral Use Only”? Note — Does parenteral tubing used within the facility have ports 1. Cohen MR. Causes of medication errors. Chapter 4. In: that are incompatible with oral syringes and enteral devices? Cohen MR, ed. Medication errors. 2nd ed. Washington — Do the ports on enteral feeding tubes used within the facil- (DC): American Pharmacists Association; 2007:56-65. ity only connect to oral syringes and catheter tip connectors

Page 88 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority for another route.19 Educate health- oral syringes. Evaluate the current — Label all access lines to indicate care professionals regarding the workflow procedures and practices which are venous lines and which are importance of not manipulating to confirm the appropriateness of feeding tubes. By indicating what the or adapting noncompatible tubing preparation of oral medications. port or line is used for, facilities can or devices in an attempt to force a All small-volume oral and enteral bring attention to preventing mental connection (e.g., tubing-to-tubing, solutions should be prepared and lapses during the medication admin- tubing-to-device). Modifying tubing administered in oral syringes.12 istration process.12 and devices may jeopardize design — Reduce the tolerance of risk by — Establish training programs and safety features.20 sharing the dangers associated with competency measures for healthcare — Ensure that oral syringes are avail- inadvertent IV injection of oral professionals regarding the use of able in the areas where they are medications. By sharing stories of certain devices. Healthcare prac- needed. It is crucial to procure the external and internal errors associ- titioners need to maintain a high appropriate drug delivery devices to ated with inadvertent IV injection level of understanding of errors and help minimize the temptation to use of oral medications, facilities can have ongoing monitoring efforts devices intended for other routes help impress upon staff the severity to ensure continued safe practices. of administration. Furthermore, of this issue and try to increase the Similarly, professional schools and by obtaining oral and parenteral awareness of this type of medication new-graduate mentorship programs syringes that look different, facilities error.12 can help improve the safe use of can add an extra precautionary mea- — Affix auxiliary labels to oral syringes syringes by including instruction sure to help signal to the practitioner indicating the medication in the on the use of oral syringes and the that the correct or incorrect device oral syringe is meant to be given via prevention of accidental injection of is being used for a particular route the oral route. Certain companies oral medications.1,12 of administration.12 Use only oral have auxiliary labels large enough syringes marked with a statement to be visible. An additional forcing CONCLUSION such as “Oral Use Only.” function would be to apply the aux- Although the inadvertent IV adminis- — Dispense, when possible, oral liquid iliary label on the tip or the plunger tration of oral medications is a rarely medications from the pharmacy in so that the label must be removed reported event, the potential for serious the most ready-to-use forms. For oral prior to administration of the patient harm—including death, as seen solutions that are not available from medication.1,12 in events reported to the Authority and manufacturers as unit-dose liquids, — For medications with oral and inject- in the literature—is great. Eliminating all have pharmacy dispense these medi- able formulations that are both medication errors involving inadvertent cations in oral syringes. Requiring available in glass vials (e.g., acetyl- IV administration of oral medications medication to be dispensed from the cysteine), consider dispensing the is challenging; however, there are strate- pharmacy in labeled, patient-specific medication in different packaging or gies that can help reduce the occurrence doses helps to reduce the manipula- with visible auxiliary labels, depend- of these errors. Healthcare practitioners tions that may occur on the patient ing on the route of administration. can start by proactively assessing the risks care units.12 For oral administration, pharmacy associated with these errors to better — Notify the pharmacy if patients could remove the drug from the understand the contributing factors (i.e., are unable to swallow capsules or manufacturer’s container and place through FMEA). By further assessing tablets. Also document this informa- the proper dose in an oral syringe the oral syringe devices and parenteral tion prominently in patient charts (or oral solution bottle if the volume medical equipment available in the and medication records. By having is greater than the largest available institution, evaluating current workflows nurses or physicians communicate oral syringe) with a label designat- and procedures for preparation of oral this information to the pharmacy, ing the drug, strength, and route of medications, and increasing the aware- medications can be prepared in liq- administration. Similar labels should ness of professionals involved in this uid form, if possible, and dispensed be placed on doses dispensed for IV practice of healthcare, practitioners can in oral syringes that are incompatible or other routes of administration. mitigate the risk of errors associated with with attachment to IV ports.12,13 Include a caution statement on med- the inadvertent IV administration of oral — Require staff to prepare and admin- ication administration records so it is medications. ister oral and enteral liquids with clear which product to use.21

NOTES

1. Institute for Safe Medication Practices. pediatric hemato-oncology ward. Pharm NDA [press release online]. 2013 May 13 Avoiding inadvertent IV injection of oral World Sci 2009 Oct;31(5):522-4. [cited 2013 May 15]. http://www. liquids. ISMP Med Saf Alert Acute Care 9. Baxa Corporation. Reducing oral medica- arborpharma.com/05132013.html 2012 Aug 23;17(17):1-2. tion wrong-route administrations and 16. Hurst M. Oral medication dispensers in 2. Kim J, Bates DW. Medication adminis- misconnections [online]. 2010 [cited 2013 clinical research. J Clin Res Best Pract 2006 tration errors by nurses: adherence to Apr 26; link no longer available]. Sep;2(9):1-3. guidelines. J Clin Nurs 2013 Feb;22(3- 10. Take steps to avoid inadvertent IV admin- 17. CNA Insurance Companies, Nurses 4):590-8. istration of nimodipine liquid. Pa PSRS Service Organization. CNA HealthPro 3. van den Bemt PM, Fijn R, van der Voort Patient Saf Advis [online] 2007 Mar [cited nurse claims study: an analysis of claims PH, et al. Frequency and determinants 2013 Mar 15]. http://patientsafetyauthor with risk management recommendations of drug administration errors in the ity.org/ADVISORIES/AdvisoryLibrary/ 1997-2007 [online]. 2009 [cited 2013 intensive care unit. Crit Care Med 2002 2007/mar4(1)/Pages/16.aspx Jun 26]. http://www.nso.com/pdfs/db/ Apr;30(4):846-50. 11. FDA Drug Safety Communication: seri- rnclaimstudy.pdf?fileName=rnclaimstudy. 4. Adachi W, Lodolce AE. Use of failure ous medication errors from intravenous pdf&folder=pdfs/db&isLiveStr=Y mode and effects analysis in improving administration of nimodipine oral cap- 18. CNA Insurance Companies, Nurses the safety of i.v. drug administration. Am J sules [online]. 2010 Aug 2 [cited 2013 Feb Service Organization. Understanding Health Syst Pharm 2005 May 1;62(9):917-20. 22]. http://www.fda.gov/Drugs/ nurse liability, 2006-2010: a three-part 5. Westbrook JI, Rob MI, Woods A, et DrugSafety/PostmarketDrugSafety approach [online]. 2011 [cited 2013 al. Errors in the administration of InformationforPatientsandProviders/ Jun 26]. http://www.nso.com/pdfs/ intravenous medications in hospital ucm220386.htm db/RN-2010-CNA-Claims-Study. and the role of correct procedures and 12. Institute for Safe Medication Practices. pdf?fileName=RN-2010-CNA-Claims- nurse experience. BMJ Qual Saf 2011 Oral syringes: a crucial and economical Study.pdf&folder=pdfs/db&isLiveStr=Y Dec;20(12):1027-34. risk-reduction strategy that has not been 19. Dyer C, Bryan G. Devices designed to 6. Hicks RW, Santell JP, Cousins DD, et al. fully utilized. ISMP Med Saf Alert Acute avoid wrong route administration of MEDMARXSM 5th anniversary data report: a Care 2009 Oct 22;14(21):1-3. drugs. Anaesthesia 2011 Dec;66(12):1181-2. chartbook of 2003 findings and trends 1999- 13. Institute for Safe Medication Practices. 20. Tubing misconnections: making the con- 2003. Rockville (MD): US Pharmacopeial Safety briefs. ISMP Med Saf Alert Acute nection to patient safety. Pa Patient Saf Convention, Inc.; 2004. Care 1999 Aug 25;4(17):1. Advis [online] 2010 Jun [cited 2013 Aug 7. Anselmi ML, Peduzzi M, Dos Santos CB. 14. Institute for Safe Medication Practices. 19]. http://www.patientsafety authority. Errors in the administration of intrave- Preventing catheter/tubing misconnec- org/ADVISORIES/Advisory nous medication in Brazilian hospitals. tions: much needed help is on the way. Library/2010/Jun7(2)/Pages/41.aspx J Clin Nurs 2007 Oct;16(10):1839-47. ISMP Med Saf Alert Acute Care 2010 Jul 21. Institute for Safe Medication Practices. 8. Bauters T, De Porre J, Janssens N, et al. 15;15(14):1-2. Confusion between various acetylcysteine Prevention of wrong route errors in a 15. Arbor Pharmaceuticals. Arbor Pharma- dosage forms. ISMP Med Saf Alert Acute ceuticals announces FDA approval of first Care 2004 Aug 12;9(16):2.

LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the causes and factors The following questions about this article may be useful for internal education and contributing to the inadvertent intra- assessment. You may use the following examples or come up with your own questions. venous (IV) administration of oral 1. Which of the following is a common contributing factor in events involving the medications. inadvertent IV administration of oral medications? — Identify oral medications at risk a. Provision of oral syringes of contributing to patient harm b. Use of a parenteral syringe to administer the medication when inadvertently administered c. Dispensing of patient-specific doses from pharmacy intravenously. d. Absence of an auxiliary label indicating medication is to be given via the — Determine the risks and issues lead- oral route ing to oral medications inadvertently being administered intravenously to 2. In events reported to the Pennsylvania Patient Safety Authority, all of the following be considered when conducting a oral medications contributed to patient harm when inadvertently administered intravenously except: failure mode and effects analysis. a. niMODipine — Select appropriate risk reduction b. NIFEdipine strategies to prevent the inadver- c. Acetylcysteine tent IV administration of oral d. Megestrol acetate medications.

Page 90 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) 3. Strategies to increase the use of oral syringes include all of the following except: a. Provide oral syringes in patient care areas. b. Educate staff about the purpose and proper use of oral syringes. c. Monitor the utilization of oral syringes to prepare and administer oral medications. d. Label all access lines to indicate which are venous lines and which are feeding tubes. Question 4 refers to the following case: The patient had been receiving medication since admission. A few days after the patient was admitted, a nurse prepared the patient’s niMODipine with a parenteral syringe to be administered via an orogastric tube. At the bedside, the medication was instead administered through the central line. Despite resuscitative measures, the patient died. 4. Which of the following strategies is most effective in preventing the inadvertent intravenous administration of oral niMODipine? a. Have pharmacy withdraw the liquid contents of the oral capsule and dispense the drug in a patient-specific and labeled parenteral syringe. b. Have pharmacy dispense the commercially available niMODipine oral solution in a patient-specific and labeled oral syringe. c. Have nurses withdraw the liquid contents of the capsule at the bedside for immediate administration to prevent contamination. d. Have materials management supply patient care areas with oral syringes. 5. Questions to consider when conducting a failure mode and effects analysis to proactively determine the risks and issues leading to oral medications inadvertently being administered intravenously include all of the following except: a. Does pharmacy prepare and dispense oral liquid medications in labeled, ready- to-use, patient-specific doses? b. Are oral syringes available and readily accessible in all patient care areas for use by nurses and other practitioners? c. Do the parenteral syringes used in the facility have needleless connectors (e.g., Luer)? d. Do the ports on enteral feeding tubes used within the facility only connect to oral syringes and catheter tip connectors? 6. All of the following are risk reduction strategies to employ when purchasing medical equipment or medications except: a. Purchase oral and parenteral syringes that look different. b. Purchase drug products in bulk containers to allow dosing flexibility. c. Purchase a different system of medical devices for each route so that they cannot be physically connected with devices for another route. d. Purchase medication administration equipment and systems that have parenteral tubing with ports that are incompatible with oral syringes and enteral devices.

This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 3—September 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar.

THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS

The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org.

ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.

The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.

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