ISMP Medication Safety Alert



[pic]

|No. |

|(11, 13)|Survey respondents reported low implementation with |Survey results indicate that improvements are still | | | |

|[pic] |storing adult, pediatric, and neonatal medications |needed to adequately protect pediatric patients from | | | |

| |separately; prescribing liquid medications in metric |harmful medication errors. Healthcare providers caring | | | |

| |doses; verifying line attachment before administering |for pediatric patients should assess their current | | | |

| |infusions; requiring practitioners to undergo specialized|practices and develop a plan to improve implementation | | | |

| |training and competency validation when working with |of the recommended “best practices” in the survey. | | | |

| |pediatric patients; and barcode scanning breast milk to | | | | |

| |match the infant with the mother’s milk prior to feeding.| | | | |

| |Only 41% of pediatric hospitals, 43% of adult-pediatric | | | | |

| |hospitals, and 19% of outpatient facilities require | | | | |

| |verifying the components of sterile preparations prior to| | | | |

| |adding them to a solution. | | | | |

| |

|NAN Alert: Medication cups with more than one dosing scale can lead to confusion |

|(13) |A nurse confused two dosing scales on a plastic |Ideally, oral syringes that measure only in mL should | | | |

|[pic] |medication cup and administered 1 dram (3.7 mL) instead |be used for oral liquid medications instead of cups. If| | | |

| |of the intended 1 mL dose of morphine sulfate 20 mg/mL |a dosing cup must be used, it should only measure in | | | |

| |oral solution, resulting in a fatal overdose. |mL. Until these cups are widely available, some | | | |

| | |suppliers can customize the cups to measure in mL only.| | | |

| | | | | | |

| |

|Ongoing BLOXIVERZ (neostigmine) and VAZCULEP (phenylephrine) confusion |

|(13) |Ongoing reports of potentially harmful mix-ups between |Make pharmacy and OR/anesthesia staff aware of the | | | |

|[pic] |look-alike vials of Bloxiverz 10 mg/10 mL and pharmacy |potential for errors with these products. Pharmacy | | | |

| |bulk packages of Vazculep 50 mg/ 5 mL have been received.|bulk packages of Vazculep should never leave the | | | |

| |Most recently, a Vazcu-lep 50 mg vial was sent to the |pharmacy. Soon, Éclat Pharma-ceuticals will be | | | |

| |operating room (OR)/anesthesia instead of Bloxiverz. If 5|packaging Vazculep in a box with “Pharmacy Bulk | | | |

| |mL of Vazculep (50 mg) had been injected, believing it |Package” highlighted in a yellow background and the | | | |

| |was Bloxiverz, the massive overdose could have caused |strength highlighted in gold. For now, the company is | | | |

| |extreme hypertension, cerebral vascular accident, or |supplying alert stickers to add to current stock to | | | |

| |death. |help staff recognize the potential for mix-ups. | | | |

| |

|Name and dosing confusion between mefloquine and MALARONE (atovaquone/proguanil) |

|(14) |Mix-ups have been reported between mefloquine and |Include the brand and generic names when prescribing | | | |

| |Malarone. Both are used for malaria treatment or |Malarone, and include the purpose (e.g., malaria | | | |

| |prophylaxis and are available in 250 mg tablet strengths.|prophylaxis or treatment) when prescribing either drug.| | | |

| |Mefloquine was prescribed daily instead of weekly, and |Confirm the drug, frequency of administration, and dose| | | |

| |mefloquine was mistaken as the generic name for Malarone |regimen with each order. In order entry systems, | | | |

| |and dispensed in error. These mistakes could lead to |establish an alert that will appear if mefloquine is | | | |

| |vomiting, syncope, QT prolongation, paranoia, and |prescribed daily and if Malarone is prescribed weekly. | | | |

| |inadequate prophylaxis. | | | | |

| |

|Guidelines for adult IV push medications |

|(14) |While the prescribing, preparation, and administration of|ISMP held a 2-day summit to address the lack of | | | |

|[pic] |IV push medications has become exceedingly commonplace as|standardized practices for IV push medications. Draft | | | |

| |part of a therapeutic standard of care, the lack of |guidelines were developed and shared on our website for| | | |

| |oversight and guidance for administration practices has |comment. The final Safe Practice Guidelines for Adult | | | |

| |led to significant variability, not only among |IV Push Medications can be found here: | | | |

| |organizations, but within organizations; even among |sc?id=563. Review the guidelines to | | | |

| |individual clinical units. |identify the associated risks and consider implementing| | | |

| | |these safe practices associated with the use of IV push| | | |

| | |medications. | | | |

| |

|Loss of potency with certain medications prepared in advance in BD syringes |

|(15, 17)|Certain medications (e.g., fentaNYL) have been found to |Limit drug exposure in plastic syringes by using them | | | |

|[pic] |lose potency when prepared in BD syringes and not |promptly after preparation. However, do not sacrifice | | | |

| |administered shortly thereafter. The rubber syringe |safety, and ensure that any process changes do not | | | |

| |stopper in certain lots interacts with these medications |increase the risk of errors. Make clinical staff aware | | | |

| |causing a loss in potency. The syringes were never |of the situation and to report unexpected changes in | | | |

| |approved for use as a storage system for drugs. This |drug effectiveness. Assign staff to watch for updated | | | |

| |calls into question pharmacy or outsourcer preparation of|information from FDA, BD, ISMP, ASHP, or other alerts | | | |

| |unit dose syringes in advance of anticipated use. |regarding the situation. | | | |

| | | | | | |

| |

|RELISTOR (methylnaltrexone) prefilled syringes look like enoxaparin and fondaparinux prefilled syringes |

|(16) |A Relistor syringe (12 mg/0.6 mL) was confused with a |Products should remain in their cartons or blister | | | |

|[pic] |generic enoxaparin syringe (150 mg/1 mL, Amphastar |packs until time of administration, although automated | | | |

| |Pharmaceuticals). The same dark navy color is used with |dispensing cabinet (ADC) drawers don’t always provide | | | |

| |both syringes. There are other similarities between the |enough space. Product barcode scanning prior to | | | |

| |syringes that could also contribute to a mix-up. |dispensing and administration will help identify | | | |

| |Enoxaparin syringes (30 mg/ 0.3 mL, Teva) also look |errors. | | | |

| |similar to fondaparinux syringes (2.5 mg/0.5 mL, Dr. | | | | |

| |Reddy’s Laboratories). | | | | |

| | | | | | |

| |

|Stocking mix-ups with intracardiac EPINEPHrine and intravenous (IV) EPINEPHrine syringes |

|(17) |Hospitals have inadvertently purchased prefilled syringes|ISMP has requested Hospira to consider making the word | | | |

|[pic] |of EPINEPHrine 1 mg/10 mL intracardiac injection rather |“intracardiac” more prominent on the label. In the | | | |

| |than the IV formulation, leading to stocking errors in |meantime, hospitals should have a process in place to | | | |

| |code carts, unit stock, and automated dispensing cabinets|ensure replacement products ordered during shortages | | | |

| |(ADCs). Suppliers failing to specify “intracardiac” on |are appropriate. | | | |

| |order lists contributed to the errors, as did a shortage | | | | |

| |of IV forms of EPINEPHrine. | | | | |

| | | | | | |

| |

|Continued BRINTELLIX (vortioxetine) and BRILINTA (ticagrelor) mix-ups |

|(18) |Brintellix 10 mg was dispensed instead of the prescribed |Establishing dose limits in order entry systems may | | | |

| |Brilinta 90 mg. The two medications were stored |help detect mix-ups if 90 mg of Brilinta is ordered but| | | |

| |side-by-side and the wrong container was selected. The |Brintellix is selected. Consider implementing computer | | | |

| |patient fell and was admitted to a hospital after taking |alerts to warn about possible confusion. Encourage | | | |

| |Brintellix for 9 days. The US Food and Drug |prescribers to include the medication’s generic and | | | |

| |Administration (FDA) has also issued a warning about |brand name and indication on orders and prescriptions. | | | |

| |errors, noting over 50 reports have been received. |Store these drugs in separate locations within the | | | |

| | |pharmacy. | | | |

| |

|Proper disposal of AUVI-Q (EPINEPHrine) autoinjector is critically important |

|(18) |An employee heard a ticking sound from a sharps container|Educate healthcare practitioners and patients about the| | | |

|[pic] |in the emergency department (ED). A “suspicious package” |proper use and disposal of the injector after replacing| | | |

| |code was initiated, and the ED was closed until an Auvi-Q|the outer case. Confusion about the ticking sound may | | | |

| |autoinjector was identified as the cause. The device had |cause patients to be diverted to other facilities | | | |

| |been brought to the hospital by a patient who had not |during investigation of the noise and potentially delay| | | |

| |reattached the outer case after use, which allowed the |treatment. | | | |

| |battery to drain until it emitted a ticking sound as it | | | | |

| |died out. | | | | |

| |

|Avoid using TPA or TNK when referring to ACTIVASE (alteplase) and TNKASE (tenecteplase) |

|(19) |The US Food and Drug Administration (FDA) continues to |Never use abbreviations for drug names, including TPA, | | | |

|[pic] |receive reports of mix-ups between Activase (alteplase) |t-PA, or TNK. Instead, for alteplase and tenecteplase, | | | |

| |and TNKase (tenecteplase) due to the use of |use the full drug names—brand, generic, or both. Remove| | | |

| |abbreviations, “t-PA” or “TPA.” Nurses involved in these |the abbreviations from all order sets, order entry | | | |

| |cases assumed that t-PA was shorthand for TNKase and |screens, and treatment protocols. Prescribers should | | | |

| |attributed the errors to confusion between TNK and TPA. |state the indication with orders to ensure the correct | | | |

| | |drug is dispensed. | | | |

| | | | | | |

| |

|Confusion between error-prone abbreviations for tranexamic acid (“TXA”) and tenecteplase (“TNK”) |

|(14) |A physician requested “TXA” for a trauma patient who |Do not use abbreviations for any drug name, including | | | |

|[pic] |required tranexamic acid (antifibrinolytic). The nurse |“TXA” or “TNK.” Review all forms of communication where| | | |

| |thought he said “TNK” and gave the physician tenecteplase|these drug names may be listed (e.g., drug information | | | |

| |(thrombolytic) in a syringe. Expecting an infusion, the |resources, storage bin labels, entries in ADCs and | | | |

| |physician detected the error. If tenecteplase had been |order entry systems) and ensure that an abbreviation | | | |

| |given, the patient might have bled. Both tranexamic acid |for either name is not used. Consider including an | | | |

| |and tenecteplase may be in an automated dispensing |alert in order entry systems and ADC databases that | | | |

| |cabinet (ADC) in the emergency department and available |states the indications for each drug and requires | | | |

| |via override. |acknowledgement prior to removal. | | | |

| |

|Engage pharmacy to ensure an independent double check of fluorouracil infusion rates |

|(15) |Over-infusion of fluorouracil has often been caused by |Ensure an independent double check of the infusion rate| | | |

|[pic] |accidental programming of the incorrect infusion rate, |by engaging the help of pharmacy. Pharmacy can set up | | | |

| |often by an oncology or home care nurse who may not have |the pump and program the initial settings, and then | | | |

| |a second healthcare professional to verify the settings |hand off the pump and medication to the nurse, who then| | | |

| |independently. |independently verifies the patient’s identification and| | | |

| | |compares what has been ordered against the pump | | | |

| | |settings entered by the pharmacist. | | | |

| | | | | | |

| |

|Methylene blue is a monoamine oxidase inhibitor (MAOI) |

|(19) |A patient taking PARoxetine received methylene blue |Facilities should treat methylene blue as a medication | | | |

| |during a procedure due to the unavailability of the |and order the drug so it can be verified/entered into | | | |

| |marker dye indigo carmine. Methylene blue is a MAOI; as a|the pharmacy computer system to allow potential drug | | | |

| |result of the interaction, the patient required |interactions to be identified. Practitioners without | | | |

| |intubation and admission to the intensive care unit. |order entry systems should incorporate drug interaction| | | |

| |Methylene blue can interact with selective serotonin |checks for methylene blue within existing processes. | | | |

| |reuptake inhibitors and serotonin norepinephrine reuptake| | | | |

| |inhibitors. | | | | |

| | | | | | |

| |

|Bendamustine (TREANDA) incompatible with some closed system transfer devices |

|(19) |A component of bendamustine, N,N-dimethylacetamide (DMA),|Determine if your facility uses a CSTD that is | | | |

|[pic] |is incompatible with closed system transfer devices |incompatible with bendamustine. | | | |

| |(CSTDs) that contain polycarbonate or acrylonitrile | | | | |

| |butadiene styrene (ABS). PhaSeal, a CSTD, does not | | | | |

| |contain these components, and after testing, it is | | | | |

| |confirmed that PhaSeal is compatible with bendamustine. | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download