ISMP Medication Safety Alert



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|(20) |One harmful and two fatal errors with low-dose oral |ISMP recommends three strategies in its Targeted | | | |

|[pic] |methotrexate have been reported. Two of the patients who |Medication Safety Best Practices: use a weekly dosage | | | |

| |suffered severe toxic events were taking no more than 20 |regimen default when oral methotrexate orders are | | | |

| |mg of methotrexate per week. Incidents occurred due to a |entered; require a hard stop verification of an | | | |

| |combination of baseline patient risk factors (renal |appropriate oncologic reason for daily orders; and | | | |

| |dysfunction, hypoalbuminemia), drug-drug interactions |educate patients prior to discharge, including | | | |

| |(amoxicillin, leflunomide, diclofenac), and medication |reminding patients that taking extra doses is | | | |

| |errors (pharmacy labeling error led to daily use). |dan-gerous, and providing them with a free ISMP | | | |

| | |hand-out (sc?id=316). Employ drug-drug and| | | |

| | |drug-disease interaction screening and resolve alerts | | | |

| | |with prescribers. Screen patients for risk factors and | | | |

| | |obtain baseline and periodic lab studies. | | | |

|Look-alike vials of cytarabine 100 mg/5 mL and vinorelbine 50 mg/5 mL |

|(20) |Cytarabine and vinorelbine vials from Hospira have the |Although practitioners should read the full label on | | | |

|[pic] |same label color and green cap, and are the same size. A |all vials, it is unsafe to store look-alike vials near | | | |

| |vial turned to expose only the final syllable of the name|one another. Isolate one of them until a secondary | | | |

| |“...bine,” which is common to both, can further increase |supply can be obtained from a different manufacturer. | | | |

| |the risk of confusion. Since cytarabine is approved for |The use of barcode scanning verification during product| | | |

| |intrathecal use, a mix-up resulting in intrathecal |preparation may also avert these types of mix-ups. | | | |

| |administration of vinorelbine is likely to result in a | | | | |

| |fatal event. | | | | |

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|Will patients ever be free from iatrogenic harm? |

|(25) |Fifteen years after the Institute of Medicine published |The panel made eight recommendations that focus on: a | | | |

| |To Err Is Human, patient safety concerns remain a serious|safety culture; oversight of patient safety; | | | |

| |public health issue. An expert panel convened by the |outcome-based safety metrics; funding for research; | | | |

| |National Patient Safety Foundation is calling for action |addressing safety across the entire continuum; support | | | |

| |by government, regulators, health professionals, and |of the healthcare workforce; partnership with patients | | | |

| |others to place higher priority on patient safety science|and families; and technology optimization. See the full| | | |

| |and implementation. |report at: free-from-harm. | | | |

|Safe administration of AGGRASTAT (tirofiban) loading doses |

|(23) |Aggrastat is only available in a premixed bag with an |If available, use smart pumps with bolus dosing | | | |

|[pic] |exit port that should not be used to withdraw the loading|features to deliver loading doses. Alternatively, the | | | |

| |dose. Product labeling recommends administering the |manufacturer recommends hanging the bag with a primed | | | |

| |loading dose directly from the bag, which can be risky |infusion set, and then withdrawing the required bolus | | | |

| |without a smart pump that automatically switches from the|dose from a port on the infusion set with a syringe. | | | |

| |loading dose rate to the maintenance infusion rate. |The bag tubing should then be clamped, and the loading | | | |

| |Manually setting the pump or using the volume to be |dose administered over 5 minutes via a port close to | | | |

| |infused to administer the loading dose could lead to |the patient’s access site. The tubing should then be | | | |

| |errors if the nurse is distracted or interrupted. |opened and the maintenance infusion started. | | | |

|Implement the 2016-2017 Targeted Medication Safety Best Practices for Hospitals |

|(25) |ISMP has launched the 2016-2017 Targeted Best Practices |Access the 2016-2017 Targeted Best Practices at: | | | |

|[pic] |to mobilize widespread adoption of a few key strategies |sc?id=417. Hospitals that have not | | | |

| |aiming to prevent repeatedly report-ed harmful medication|implemented the six 2014-2015 Targeted Best Practices | | | |

| |errors. The five new Targeted Best Practices deal with |are encouraged to do so as a priority, while | | | |

| |safe storage of neuromuscular blocking agents, use of |implementing the five new 2016-2017 Targeted Best | | | |

| |fully enabled smart pumps when administering high-alert |Practices. | | | |

| |medications, making reversal and rescue agents available,| | | | |

| |eliminating storage of 1 liter bags of sterile water in | | | | |

| |patient care areas, and verifying the ingredients prior | | | | |

| |to mixing when compounding sterile preparations. | | | | |

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|Key vulnerabilities in the surgical environment: Container mix-ups and syringe swaps |

|(22) |Container mix-ups and syringe swaps are problematic in |Standardize the anesthesia workspace and concentrations| | | |

|[pic] |perioperative areas. During knee surgery, a woman |of high-alert medications. Remove used and unused | | | |

| |received tranexamic acid intrathecally after the 10 mL |medications from the anes-thesia workspace after | | | |

| |vial was mixed up with the same size vial of bupivacaine.|completing each case. Employ barcode scanning of | | | |

| |Nearly a dozen of these mix-ups are in the literature, |medications and an automated syringe label printer. | | | |

| |some leading to fatalities including a young mother in |Deliver all drug infusions via a smart pump with | | | |

| |labor. A study found that 1 in 20 perioperative |activated dose-checking software. Require the use of | | | |

| |medication administrations and half of all surgical |commercially available, outsourced, or | | | |

| |procedures resulted in a medication error—-more than |pharmacy-prepared syringes and infusions. Provide | | | |

| |one-third of the errors led to patient harm. |dedicated anes-thesia automated dispensing cabinets in | | | |

| | |operating rooms and procedural areas that communicate | | | |

| | |with the pharmacy when drugs are removed. | | | |

|Confusing volume on OBIZUR (anti-hemophilic factor [recombinant], porcine sequence) vial |

|(22) |Pharmacy staff have been misled by the “3 mL” designation|Make pharmacy staff (e.g., pharmacists, technicians) | | | |

| |on the Obizur label, which refers to the vial’s size (to |aware of the potential for errors when reconstituting | | | |

| |facilitate swirling of the reconstituted contents), not |this drug and preparing patient-specific doses. Include| | | |

| |the drug volume after reconstitution. Although a 1 mL |a note in the pharmacy computer and on technician | | | |

| |syringe of diluent is provided, a pharmacist assumed the |preparation labels that the final volume in these vials| | | |

| |volume in the vial would swell to 3 mL after |is 1 mL after reconstitution. The company has agreed to| | | |

| |reconstitution. The pharmacist provided the technician |change the label to reduce confusion. | | | |

| |with instructions to place 60 mL of the drug in a small | | | | |

| |infusion bag, when only 20 mL was needed for the | | | | |

| |patient’s dose. | | | | |

|Oral devices with mL-only dosing marks |

|(23) |Mix-ups when measuring oral liquid medications have |More oral devices, including oral syringes and dosage | | | |

| |occurred when using cups or syringes with household or |cups, with metric-only dose scales are becoming | | | |

| |other non-metric measures. In order to prevent errors, we|available and should be used to prevent measurement | | | |

| |recommend purchasing oral liquid dosing devices that only|errors. Some of these dosing devices have gradation | | | |

| |display the metric scale. However, current metric-only |markings in black, making the scales easier to read. | | | |

| |dosage cups may have scales that are embossed on clear | | | | |

| |plastic, making them difficult to read. | | | | |

|Continued confusion between calcium gluconate and sterile water for injection vials |

|(20) |Close calls and mix-ups with look-alike 10 mL vials of |Fresenius Kabi has made label changes to its calcium | | | |

|[pic] |Fresenius Kabi calcium gluconate 1 g/10 mL and Hospira |gluconate product to reduce similarities. The company | | | |

| |sterile water for injection continue. A pharmacy recently|anticipated a late November or December (2015) release | | | |

| |sent a vial of calcium gluconate instead of sterile water|of this product. Consider switching to a 20 mL vial of | | | |

| |for injection to reconstitute a vial of ampicillin for a |sterile water to help differentiate the products. | | | |

| |neonate. Fortunately, the nurse realized that an |Barcode scanning, alerting staff to this risk, and | | | |

| |incorrect diluent had been sent. |storing these products apart may help prevent errors as| | | |

| | |well. | | | |

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|Diluent for FIRST brand of oral vancomycin (CurtisPharma) administered in error |

|(21) |This brand of oral vancomycin is supplied as a |When using this product, prepare doses in the pharmacy | | | |

| |compounding kit containing two bottles, one with drug |before dispensing. Despite the expense, provide a few | | | |

| |powder and the other with diluent. Both bottles list |oral vancomycin capsules in an automated dispensing | | | |

| |“Vancomycin 25” or “Vancomycin 50” at the top. A nurse |cabinet to be used when the pharmacy is closed. | | | |

| |removed one of the bottles labeled “vancomycin” from the | | | | |

| |kit and administered only the diluent to a patient. | | | | |

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|Farewell to ratio expressions on labels of single entity drugs |

|(24) |Ratio expressions of single entity drug products will no |Inform prescribers and other healthcare professionals | | | |

|[pic] |longer be allowed as of May 1, 2016. To prevent |about the upcoming changes, and encourage them to use | | | |

| |confusion, orders for these drugs after May 1 should |the new dosing nomenclature when referring to these | | | |

| |include a metric dose. For example, if a prescriber calls|medications. | | | |

| |for “1:10,000 EPINEPHrine” during a code and the product | | | | |

| |label displays the strength as 0.1 mg/mL rather than the | | | | |

| |ratio expression, practitioners could administer the | | | | |

| |wrong strength. | | | | |

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|Inadequate treatment doses of HYPERTET (tetanus immune globulin [TIG]) |

|(20) |The Centers for Disease Control and Prevention (CDC) |Educate prescribers, pharmacists, nurses, and other | | | |

| |reviewed tetanus cases in California over 6 years. Some |practitioners about the differences between the | | | |

| |patients received a 250 unit postexposure prophylaxis |treatment and postexposure prophylaxis doses. Consider | | | |

| |dose instead of a 3,000-6,000 unit treatment dose of TIG,|adding alerts to computerized prescriber order entry | | | |

| |due in large part to prescribing errors. The lack of a |systems and pharmacy computer systems. Place reminders | | | |

| |specific treatment dose in the TIG package insert and |to verify whether the product is being used for | | | |

| |availability in 250 unit prefilled syringes contributed |treatment or prophylaxis, and include appropriate doses| | | |

| |to the inadequate dosing. |for both, in storage areas or on automated dispensing | | | |

| | |cabinet screens. | | | |

|Used oxymetazoline nasal spray restocked because tamper-resistant seal looked intact |

|(23) |A used oxymetazoline nasal spray was placed back in |Once a product is opened, staff should remove the | | | |

| |storage with unused sprays. The used product was almost |entire tamper-resistant seal. Review organizational | | | |

| |administered to a patient, except the physician noticed |processes to ensure appropriate steps are in place to | | | |

| |blood on the bottle tip. During initial use, the cap had |distinguish opened containers from unopened containers.| | | |

| |been twisted off but the tamper-resistant seal remained |Consider applying an additional tamper-resistant | | | |

| |largely intact. |sticker to products when necessary. | | | |

|Continued BLOXIVERZ (neostigmine) and VAZCULEP (phenylephrine) mix-ups |

|(20) |Mix-ups continue with look-alike vials of Bloxiverz 10 |Eclat Pharmaceuticals, the manufacturer of both drugs, | | | |

|[pic] |mg/10 mL and pharmacy bulk packages of Vazculep 50 mg/5 |is changing the label and sent out auxiliary labels to | | | |

| |mL despite past warnings in this newsletter, a national |be used with current stock of Vazculep 50 mg/5 mL | | | |

| |alert, and a letter from the manufacturer. Recently an |products. While older product remains in circulation, | | | |

| |operating room automated dispensing cabinet (ADC) was |use of the auxiliary labels is necessary. Also, | | | |

| |accidentally stocked with Vazculep instead of Bloxiverz, |Vazculep 5 mL and 10 mL vials should only be stored in | | | |

| |which was used in error to reverse neuromuscular |the pharmacy, not in ADCs in patient care areas, and | | | |

| |blockade. The patient required reintubation, mech-anical |kept away from supplies of Bloxiverz. Barcode scanning | | | |

| |ventilation, and treatment of hypertension. |of containers could prevent mix-ups. | | | |

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