ISMP Medication Safety Alert



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|No. |

|(21) | | | | | |

|[pic] |With the increasing number of people who have ambulatory |Establish procedures for the management of patients who | | | |

| |infusion pumps, it is likely that hospitals will |present to the hospital with an infusion device. To help, | | | |

| |encounter patients with these types of devices. During |ISMP developed guidelines for managing patients with | | | |

| |hospitalization, patients may benefit from continued use |insulin pumps during hospitalization, which cover the | | | |

| |of certain ambulatory pumps, including insulin pumps, if |initial assessment process, next steps for patients who | | | |

| |they are mentally and physically capable. A survey |meet or do not meet criteria for self-management of their | | | |

| |conducted last year (sc?id=2817) found a |pumps, and inpatient management of patients who self-manage| | | |

| |high degree of variability in the assessment and |their pumps. View the guidelines at: | | | |

| |management of patients using ambulatory devices. |sc?id=2857. | | | |

|Transdermal fentaNYL should not be stocked in the emergency department (ED) |

|(21) | | | | | |

|[pic] |An 89-year-ld, opioid-naïve man in the ED with |Do not stock fentaNYL patches in the ED. Have a pharmacist | | | |

| |intractable back pain was prescribed and administered a |review orders for the patches to verify that the patient is| | | |

| |50 mcg/hour fentaNYL patch. A pharma- cist caught the |opioid-tolerant before it is dispensed. Also build stops | | | |

| |error when the admitting physician tried to continue the |into fentaNYL patch orders to require prescribers to verify| | | |

| |order for transdermal fentaNYL on admission. |the patient meets prescribing criteria. | | | |

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|Lipid rescue for bupivacaine toxicity |

|(23) | | | | | |

|[pic] |A pregnant patient experienced stupor, seizures, |Ensure appropriate rescue agents and directions for their | | | |

| |hypotension, and tachycardia after she received fentaNYL |use are available in clinical areas. Develop standardized | | | |

| |and bupivacaine IV instead of penicillin G. Prompt |protocols that permit emergency administration of a lipid | | | |

| |recognition of the error led to treatment with fat |rescue agent to treat bupivacaine toxicity to prevent any | | | |

| |emulsion. The patient recovered and delivered a healthy |delays in administration. | | | |

| |infant. | | | | |

|Harm or death from phenytoin injection errors |

|(23) | | | | | |

| |The National Health Service Improvement in the UK issued |Weigh each patient in metric units on admission or during | | | |

| |an alert about errors with injectable phenytoin. |an emergency department encounter. Avoid the use of a | | | |

| |Contributing factors included: no weight or wrong |stated, estimated, or historical weight. Review the | | | |

| |estimated weight, failure to take into account existing |patient’s medication history before prescribing or | | | |

| |phenytoin levels when prescribing loading doses, wrong |dispensing loading doses of phenytoin to make sure the | | | |

| |infusion rates or diluent, loading dose continued as a |patient was not taking it previously. Pharmacy should | | | |

| |maintenance dose, and lack of monitoring. |prepare and dispense all IV piggyback doses. | | | |

|LANTUS (insulin glargine) overdose tied to confusing vial label |

|(23) | | | | | |

|[pic] |A patient received 900 units of Lantus subcutaneously due|Educate staff regarding safe insulin dosing ranges and | | | |

| |in part to a confusing label on the Sanofi vial. If |injection technique. However, the best way to avoid a | | | |

| |turned a certain way, the label lists “10 mL” directly |similar error is for the pharmacy to prepare, label, and | | | |

| |below “100 units.” The nurse thought she had to |dispense patient-specific basal insulin doses. We have | | | |

| |administer 9 mL of insulin to deliver a 90 unit dose. The|notified Sanofi and the US Food and Drug Administration | | | |

| |hospital normally used Lantus pens, but the maximum dose |about the labeling issue that contributed to a | | | |

| |that can be administered with the pen is 80 units, so the|misunderstanding of the concentration. | | | |

| |pharmacy dispensed a 10 mL vial. Other contributing | | | | |

| |factors included unfamiliarity with safe dosing ranges | | | | |

| |and the maximum volume for subcutaneous injections. | | | | |

|Accidental intravenous (IV) infusion of a heparinized irrigation solution |

|(24) | | | | | |

|[pic] |A bag of lactated ringer’s with added heparin intended |Have pharmacy prepare or provide commonly used irrigation | | | |

| |for wound irrigation was mistakenly administered IV |mixtures to the operating room (OR) in pour bottles or bags| | | |

| |during a surgical procedure. The bag was not labeled as |of a different size (e.g., 2 L) with a “FOR IRRIGATION | | | |

| |containing heparin. IV administration of bladder/wound |ONLY” label. Label all irrigation solutions immediately | | | |

| |irrigations often involves confusion between unlabeled |when an additive is mixed into the solution. Consider | | | |

| |solutions, mix-ups between irrigation and parenteral |mixing the heparin in sodium chloride 0.9% pour bottles. | | | |

| |solution bags, or mix-ups between irrigation and venous |Separate fluid replacement and irrigation solutions. | | | |

| |access lines. | | | | |

|Don’t bring medications/solutions to the bedside or procedural area before they are ordered or needed |

|(20) | | | | | |

|[pic] |Bringing a controlled substance or any |Any controlled substance or medication/solution needed for | | | |

| |medication/solution into the patient’s room, bedside, or |a procedure should be obtained immediately before use. If | | | |

| |procedural area before it is ordered or needed introduces|obtained by an individual not administering it, a time-out | | | |

| |the risk that it might be mistaken as a different |process should include verification of the drug/solution as| | | |

| |drug/solution that is packaged similarly. One fatal event|it is handed to the practitioner who will be administering | | | |

| |involved a nurse who mistakenly administered fentaNYL and|it. Barcode scanning is also recommended prior to drug | | | |

| |bupivacaine IV instead of penicillin. |administration. | | | |

|GENVOYA (elvitegravir, cobicistat, emtricitabine, tenofovir alafenamide) and STRIBILD (elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate) |

|(21) | | | | | |

| |We continue to receive reports of mix-ups between Genvoya|Examine how these drugs are displayed in computer systems, | | | |

| |and Stribild. Both share the same indication, are dosed |and take steps to differentiate between the two by listing | | | |

| |once daily, and the tablets look nearly identical. The |the ester form of tenofovir in all bolded uppercase letters| | | |

| |products differ only in the ester derivative of tenofovir|(e.g., tenofovir DISOPROXIL FUMARATE vs. tenofovir | | | |

| |but are not interchangeable. Product labeling and |ALAFENAMIDE) and by including their brand names. | | | |

| |computer presentations of the generic names list the | | | | |

| |different forms of tenofovir as the last ingredient, | | | | |

| |making it easy to miss the difference. | | | | |

|Problems using the TANZEUM (albiglutide) pen (in QuarterWatch) |

|(20) | | | | | |

| |Tanzeum has a lengthy and complicated process for |Refer patients using Tanzeum to the manufacturer’s website| | | |

| |reconstitution that takes at least 30 minutes and |where they can access an instruction manual, as well as a | | | |

| |requires more than a dozen steps. During a 12-month |brief informational video on proper reconstitution | | | |

| |period, the US Food and Drug Administration (FDA) |technique (how-to-use.html). | | | |

| |received 1,500 reports of patients using the pen | | | | |

| |incorrectly. | | | | |

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|Standardize 4 Safety: American Society of Health-System Pharmacists (ASHP) standardized concentrations for intravenous (IV) medications |

|(22) | | | | | |

| |ASHP announced availability of the first list of |Use the new standardized IV concentrations to help reduce | | | |

| |recommended concentrations for adult IV continuous |compounding errors, to standardize smart pump libraries, | | | |

| |infusions (sc?id=2830) developed as part of |and reduce the risk of selecting the wrong concentration | | | |

| |an interprofessional effort to reduce medication errors. |from computer drop-down lists. | | | |

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|Do not give ZURAMPIC (lesinurad) without a xanthine oxidase inhibitor |

|(22) | | | | | |

| |Zurampic carries a boxed warning about the risk for acute|AstraZeneca plans to offer a combination product with | | | |

| |renal failure when used without a xanthine oxidase |lesinurad and allopurinol in the future. Until a | | | |

| |inhibitor, such as allopurinol or febuxostat. In clinical|combination product is available, develop a linked order | | | |

| |trials, patients taking this drug alone experienced renal|set that requires both drugs to be ordered, and place | | | |

| |failure at a rate of 9.3% compared to 1% when taken with |reminders in computer systems and on auxiliary labels. | | | |

| |a xanthine oxidase inhibitor. | | | | |

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|Potential issues with SOLIQUA 100/33 (insulin glargine, lixisenatide) and XULTOPHY 100/3.6 (insulin degludec, liraglutide) |

|(25) | | | | | |

|[pic] |Two new combination insulin/glucagon-like peptide-1 |To indicate to users that these products contain two | | | |

| |(GLP-1) agonists, Soliqua 100/33 and Xultophy 100/3.6, |different ingredients, computer system drop-down lists and | | | |

| |are dosed in insulin units, which could lead |pharmacy communications should use brand names if your | | | |

| |practitioners to mistakenly think the products contain |system allows. If using generic names, make sure both | | | |

| |only insulin and prescribe an additional GLP-1 agonist |ingredients are displayed and not truncated. Educate | | | |

| |separately. Also, both products may be used at doses |patients taking these products to make sure they understand| | | |

| |lower than currently approved for the single GLP-1 |they contain both insulin and a GLP-1 agonist. | | | |

| |component. Thus, converting between the combination | | | | |

| |products and the individual ingredients could be | | | | |

| |problematic. | | | | |

|Vecuronium and vancomycin vial mix-ups |

|(23) | | | | | |

|[pic] |Mylan’s vancomycin 1 g vial and vecuronium 20 mg vial |If both of these manufacturer’s drugs are used in your | | | |

| |look nearly identical when the caps are removed. Both of |facility, consider purchasing one of the products from an | | | |

| |these vials are stored in the pharmacy and used in the |alternate manufacturer to avoid potential mix-ups. | | | |

| |operating room. | | | | |

|Hydroxyurea and hydrOXYzine mix-up |

|(25) | | | | | |

|[pic] |During order entry, hydroxyurea (an institutionally |Use dose range checking software to detect doses for | | | |

| |compounded liquid form of 100 mg/mL) was selected from a |hydroxyurea that are outside the normal range. It may also | | | |

| |drop-down list instead of hydrOXYzine for itching. The |be helpful to differentiate hydroxyurea from hydrOXYzine by| | | |

| |patient received hydroxyurea 25 mg every 6 hours for 2 |using the brand name HYDREA or DROXIA. We also encourage | | | |

| |days until medical staff questioned why the patient was |prescribers to include an indication for all medication | | | |

| |receiving this drug. |orders. | | | |

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