April - June 2017 ISMP Quarterly Action Agenda One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and to use that information to prevent similar problems at your practice site. To promote such a process, the following selected items from the April–June 2017 issues of the ISMP Medication Safety Alert! have been prepared for leadership to use with an interdisciplinary committee or with frontline staff to stimulate discussion and action to reduce the risk of medication errors. Each item includes a brief description of the medication safety problem, a few recommendations to reduce the risk of errors, and the issue number to locate additional information. 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 (www.ismp.org/sc?id=479 ). The Action Agenda is also available for download in a Microsoft Word format ( www.ismp.org/sc?id=2965 ) that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Continuing education credit is available for nurses at: www.ismp.org/sc?id=480 .
Key: — ISMP high-alert medication Issue Date Problem Recommendation Organization Assessment Action Required/Assignment No. Completed Wholesaler totes may be a source of fungal contamination (8, 9) Two hospitals reported aerosolized Regularly inspect arriving totes and fungal contamination in cleanrooms other packaging, and take immediate believed to be caused by contaminated action if needed, including follow-up wholesaler totes. In one hospital, with the wholesaler or supplier to Penicillium was discovered in both the resolve the issue. Follow best anteroom and a laminar flow hood. practices developed by CriticalPoint Soon after, practitioners noticed the (www.ismp.org/sc?id=2903 ) that call © 2
0 tote covers from the drug wholesaler for the use of a sporicidal agent when 1 7
I S had visible mold growing on them. unpacking supplies from corrugated M P Cladosporium , Aspergillus , and Penicil- cardboard boxes before bringing lium species were cultured from the them into a cleanroom. (Sterile totes. Bringing grossly contaminated isopropyl alcohol is ineffective in totes into a pharmacy increases the risk eradicating these types of micro- of contamination in the cleanroom. organisms.) Missed heparin-induced thrombocytopenia (HIT) diagnosis from heparin-coated device (9) During a procedure, a wire and catheter Compile a list of drug-eluting stents had been dipped several times in a and commercially available and/or solution containing heparin before user-applied medication-coated cath- insertion to prevent clotting. The patient eters/devices used in the facility. developed thrombocytopenia 6 days Establish a system to document in the later. A lab test for HIT was positive but patient’s record any exposure to ignored because the primary care medication-containing devices. Look physician did not know about the for hidden sources of medications if undocumented source of heparin. Once symptoms arise in patients suggesting home, the patient suffered a thrombosis possible HIT, an allergic reaction, or in his arm, requiring amputation. Hidden other drug reaction. Discontinue all and undocumented sources of heparin sources of heparin (including heparin- exposure make a diagnosis of HIT diffi - coated catheters and heparin cult. flushes), and initiate treatment if HIT is suspected or diagnosed.
July 13, 2017 ISMP MedicationSafetyAlert! Ò QAA 1 April - June 2017 ISMP Quarterly Action Agenda
Issue Date Problem Recommendation Organization Assessment Action Required/Assignment No. Completed Unsafe practice: Reuse of a saline flush syringes (7) A nurse was reusing prefilled saline Educate nurses about injection and flush syringes for multiple patients for 6 infusion safety, including recognition months before the unsafe practice that any form of syringe and/or needle was discovered. She believed it was reuse is dangerous. Review related cost-effective and safe if no fluids policies and procedures to ensure that were withdrawn into the syringe. the ISMP Safe Practice Guidelines for Follow-up with the 392 affected Adult IV Push Medications have been patients identified one documented incorporated ( www.ismp.org/sc?id= case of hepatitis C transmission 563 ). Monitor adherence with proper caused by reusing the flush syringes. injection and infusion techniques.
Unsafe practice: Administration of a product with a precipitate (7) Six cases have been reported involving Educate nurses, physicians, pharma - dispensing and IV administration of cists, and pharmacy technicians to products despite a visible precipitate. In always observe medications and one case, a nurse administered a solutions for precipitates, and to avoid © 2 0
1 cloudy calcium gluconate and potas - dispensing or administering the 7
I S M sium phosphate infusion, which led to product if precipitates are visible or a P fatal pulmonary emboli. In another solution that should be clear is cloudy. case, a baby received 10-fold over- The use of an in-line filter for solutions doses of etoposide infusions with that are prone to precipitation can help visible precipitates for 5 days. In a third prevent particulates from entering the case, a compounding error with PRO- body; however, precipitates can still VAYBLUE (methylene blue) led to pre- form in the tubing below the filter, and cipitation of the drug, which was admin - filters may become blocked, signaling istered despite visible particulates. a need to investigate. VinCRIStine extravasation unlikely with minibags (10) Accidental mix-ups between intra- Twelve months of data collected at The thecal medications and IV vin CRIStine Johns Hopkins Hospital found zero have been uniformly fatal. One barrier cases of extravasation among 1,300 to standardizing vin CRIStine adminis - minibag administrations of IV vin- tration in minibags to prevent this error CRIStine after changing from adminis - is that some nurses believe the risk of tration via syringe ( www.ismp.org/sc? extravasation is higher than when id=2921 ). ISMP Targeted Medication administering the drug manually via IV Safety Best Practice #1 calls for dilution push. of IV vin CRIStine in a minibag to reduce the risk of mix-ups with intrathecal drugs (www.ismp.org/sc?id=417 ).
July 13, 2017 ISMP MedicationSafetyAlert! Ò QAA 2 April - June 2017 ISMP Quarterly Action Agenda
Issue Date Problem Recommendation Organization Assessment Action Required/Assignment No. Completed Problems associated with the use of new BD U-500 insulin syringes (9) Prescriber confusion led to the Move the “U-500” designation to the inappropriate prescribing of U-500 left of the insulin syringe entry in insulin syringes for outpatients taking prescribing systems. If U-500 syringes U-100 insulin. In another organization, are not stocked, consider using the U- U-500 syringes were repeatedly 500 insulin pen to prevent dosing errors prescribed in error via electronic rather than using a tuberculin or U-100 systems because the “U-500” desig - syringe for U-500 insulin. During med- nation was to the far right of the entry ication reconciliation, confirm the type and overlooked. Other issues include of insulin syringe or pen patients are its lack of a needle guard to protect using to administer U-500 insulin. Refer against needlesticks, and a capacity to to ISMP’s Guidelines for Optimizing measure only up to 250 units when Safe Subcutaneous Insulin Use in patients may require higher doses. Adults (www.ismp.org/sc?id=2966 ). Don’t leave “Meds to Beds” prescription bags at bedside (8) “Meds to Beds” programs bring Affix an auxiliary label to the bag of © 2
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M side prior to discharge and provide patients that the medications are not P pharmacists with an opportunity to for use while in the hospital. Do not educate patients about their medica - leave the medications unsecured at tions. We recently learned of an event in the bedside. A plan should be estab - which a nurse gave a patient his lis hed regarding where to secure these medications, and then the patient medications until discharge, after a opened the bag of discharge medica - pharmacist has reviewed the m with tions left at the bedside and nearly took the patient, and what to do if the patient the same medications. is not in the room at the time of delivery. Safeguard oral chloral hydrate liquid if used for pediatric procedural sedation (10) An ISMP survey indicates that oral If the drug is used in your facility, it chloral hydrate liquid is being should be prescribed in mg, not compounded in some pharmacies for volumetric doses alone. Compound the pediatric procedural sedation. About 1 drug using barcode technology (or an in 5 reported patients spitting out the independent check), and dispense it in dose or vomiting, sedation failures, and the exact prescribed amount. Only prolonged sedation. Although most do trained healthcare workers should not believe chloral hydrate has a role in administer the drug in a facility with pediatric sedation, 18% recommend its immediate access to emergency use in certain settings (e.g., radiology, equipment/medication, and the child neuroimaging, emergency department, should be monitored by a practitioner dental procedures in a hospital). once the drug has been administered.
July 13, 2017 ISMP MedicationSafetyAlert! Ò QAA 3 April - June 2017 ISMP Quarterly Action Agenda
Issue Date Problem Recommendation Organization Assessment Action Required/Assignment No. Completed Death due to a pharmacy compounding error (12) A lethal dose of baclofen suspension Use ready-made products whenever was administered to a child instead of possible. If compounding is necessary, tryptophan suspension due to a selec - ensure compliance with accepted tion error during the compounding standards (USP <795>) and conduct an process. The ingredients were not independent double check of all ingre - independently verified prior to com- dients prior to mixing, using barcode pounding the oral solution. The trypto - technology to augment the process. phan and baclofen (used for topical Label chemicals used for com- preparations) were both supplied by the pounding with unique item numbers same manufacturer, with similarly and barcodes. Segregate compound- designed labels, a white powder, and ing ingredients intended for a single stored right next to each other. route of administration. Despite technology, verbal orders persist, read back is not widespread, and errors continue (10) An ISMP survey on verbal orders Limit verbal orders to emergencies or suggests they are still used frequently when the prescriber is physically un- © 2
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M half read back verbal orders less than fax orders. Except in emergencies, do P 50% of the time, and 9% never read back not allow verbal orders for entire order the orders. The potential to mishear or sets when admitting or discharging mistranscribe verbal orders is high patients. Transcribe verbal orders given different accents, dialects, pro- directly into the medical record, and nunciations, sound-alike drug names, read back the order. Assess how pre- and background noise. About 14% of valent reading back orders is, and take respondents were aware of an error any necessary steps to help practi - caused by verbal orders in the past year. tioners fulfill this safety check, which is the single most important strategy to reduce errors with verbal orders. Divided methotrexate doses may lead to overdoses (7) A patient with arthritis was hospitalized If possible, program computers to after taking daily methotrexate, misun - default to a weekly dose, avoid derstanding the directions on the confusing instructions on a patient’s prescription vial to “Take 6 tablets by prescription label if divided dosage mouth weekly. Take 3 tablets in AM and regimens are used, and verify patient 3 tablets in PM.” The use of divided oral understanding of the directions for use. doses at 12 hour intervals, given as a When possible, prescribe the drug as a course dose once weekly, has once weekly single dose, and dispense contributed to accidental daily the drug in 4-week dose packs when methotrexate administration. used for non-oncologic indications.
July 13, 2017 ISMP MedicationSafetyAlert! Ò QAA 4