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ISMP Medication Safety Alert(14) by pptfiles


									                                                                                 April – June 2010

                                          ISMP           QuarterlyActionAgenda
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 Issue                     Problem                                Recommendation                Organization                               Action Required/                     Date
  No.                                                                                            Assessment                                   Assignment                      Completed
                                                                     Common risks associated with heparin
(7)       Since 1996, ISMP has published   Identify and remove
          more than 100 reports about      barriers to utilizing
          heparin errors. The latest       smart pump technology.
          event involved a child who       Examine internal errors
          died after receiving a large     associated with heparin
          overdose of IV heparin due to    and common risks (e.g.,
                                           programming errors, mix-
          an infusion pump setting error
                                           ups with other drugs,
          that was not detected during a
                                           compounding errors,
          verbal checking process. The     concomitant
          pump was a smart pump with a     administration of
          drug library and dose-checking   heparin-type products)
          capabilities, but this feature   listed in Table 1
          was not utilized.                (
                                           408.asp) to identify
                                           weaknesses. Implement key
                                           improvement strategies
                                           found in Table 1 and in
                                           the ISMP Medication
                                           Safety Self Assessment
                                           for Antithrombotic
                          Confusion between organ preservation solutions (i.e., VIASPAN and SPS-1) and IV containers
(7)       Cold storage solutions used      Alert operating room staff
          to preserve harvested organs     of the possibility for mix-
          are available in plastic bags ups between organ
          that resemble IV bags and        preservation solutions and

 July 15, 2010                                                      ISMP MedicationSafetyAlert!           
                                                                                                                                                                                      QAA 1
                                                            April – June 2010
                                               ISMP   QuarterlyActionAgenda
Issue              Problem                       Recommendation                 Organization          Action Required/     Date
 No.                                                                             Assessment              Assignment      Completed
        also contain a port that will    IV containers. If organ
        accommodate IV tubing. An        preservation solutions are
        organ procurement team left a    routinely stored at your
        liter bag of ViaSpan in a        hospital, sequester the
        hospital where it was later      solutions away from other
        returned to the hospital’s       IV solutions and apply
        pharmacy with other IV           auxiliary warning labels to
        solutions. Inadvertent IV        the outerwrap noting that
        administration of organ          this concentrated
        preservation solution would      electrolyte solution is to
        cause cardiac arrest due to      be used only for the
        the high amount of potassium.    storage or flushing of
                                         harvested organs.
                                                 Another fatal event with IV bupivacaine
(10)    ISMP previously described an     Obstetrical units need to
        event involving a young          evaluate and address
        pregnant woman who died after    bupivacaine toxicity that
        she accidently received an IV    results from accidental IV
        infusion of epidural             injection. Inherent risks
        bupivacaine and fentaNYL.        associated with routinely
        More recently, news media        prescribing, dispensing,
        from the United Kingdom          storing, and administering
        reported that a hospital         both epidural and IV
        trust would be sentenced by a    solutions, and other
        court after one of its own       medications during labor and
        nurses died when she was         delivery should also be
        given IV bupivacaine instead     identified and addressed.
        of saline shortly after
        giving birth.

                                        Common pitfalls when conducting a root cause analysis (RCA)
(8)     ISMP continues to observe        Ensure that the RCA
        common pitfalls encountered      includes an accurate
        while conducting a RCA, often    sequence of events.
        rendering the process less       Investigate “what
        useful than intended. Common     normally happens” rather
        problems include: failing to     than just relying on
                                         “what policies and
        establish a sequence of
                                         procedures require.”
        events; over-reliance on
                                         Identify conditions that
        written policies and
July 15, 2010                                     ISMP MedicationSafetyAlert!   
                                                                                                                               QAA 2
                                                             April – June 2010
                                                ISMP   QuarterlyActionAgenda
Issue               Problem                       Recommendation                 Organization           Action Required/     Date
 No.                                                                              Assessment               Assignment      Completed
        procedures to illustrate what     led to at-risk behaviors,
        normally happens when             and discover the deep
        providing care; failure to        system-based causes of
        conduct investigations for        events (see probing
        all at-risk behaviors and         questions in Table 2 at:
        human errors identified; not
        seeking external information      letters/acutecare/articles/
        about similar adverse events;     20100422.asp). Search
        selecting weak error-             professional literature for
        reduction strategies; and         similar events, and choose
        others.                           error-reduction strategies
                                          which are more resistant to
                                          human error. Carry out
                                          action plans and measure
                                          your success.

                           Propofol container labels highlight the percent concentration, not the mg/mL strength
(8)     Propofol 5 mg (0.5 mL) was        To reduce the risk of
        ordered for an agitated           calculation errors,
        pediatric patient following       hospitals using the imported
        extubation. The nurse             product should add an
        accidently gave 5 mL (50 mg)      auxiliary label to draw
        of propofol. The propofol         attention to the mg/mL
        (DIPRIVAN) vial had a             strength. Pharmacy-applied
        pharmacy label covering the       labels, however, should
        mg/mL strength, so the only       never obscure critical
        visible portion of the label      information on the
        stated “propofol 1%.” Also,       manufacturer’s label.
        due to the propofol shortage,
        the imported product sold by
        APP Pharmaceuticals and
        manufactured by Fresenius
        Kabi, only highlights the
        strength as 1%, making it
        difficult to determine the mg
                                                 Prevent vinCRIStine wrong route injections
(10)    More than 50 fatalities have       Safety practices to
        been reported after               prevent this error can be
        administering vinCRIStine via     found at:
July 15, 2010                                      ISMP MedicationSafetyAlert!   
                                                                                                                                 QAA 3
                                                            April – June 2010
                                               ISMP   QuarterlyActionAgenda
Issue               Problem                      Recommendation                 Organization          Action Required/     Date
 No.                                                                             Assessment              Assignment      Completed
        the intrathecal route; the few
        patients who survived this        acutecare/
        type of error have permanent      articles/20060223.asp and
        neurological deficits. The
        most recent fatal event           cines/publications/drugal
        occurred in an adult patient      erts/Alert_115_vincristin
        who had been receiving IV         e.pdf. ISMP and the World
        vinCRIStine as well as            Health Organiza-tion
        intracerebroventricular           suggest dispensing and
        methotrexate through an Ommaya    administering vinCRIStine
        reservoir. The patient            diluted in a minibag, and
        inadvertently received            to separate IV and spinal
        vinCRIStine via the Ommaya        medication delivery
        reservoir.                        times. Medica-tion safety
                                          teams/committees may want
                                          to view the free FDA
                                          Patient Safety Video on
                                          this topic at:

                            Safe practice with the once daily opioid EXALGO (HYDROmorphone extended-release)
(10)    Recently FDA approved Exalgo,    When prescribing Exalgo,
        which is indicated for the      include the proprietary
        management of moderate to       name, and if the
        severe pain in opioid-          established name is used,
        tolerant patients requiring     spell out “HYDROmorphone
        continuous opioid analgesia     extended-release.” If
        for an extended period of       prescribing immediate-
        time. Confusion between         release HYDROmorphone, do
        immediate- and extended-        not attach modifiers such
        release products could result as “IR.” Before dispensing
        in an overdose, which may       or administering Exalgo,
        lead to serious adverse         verify that the patient is
        events such as respiratory      opioid-tolerant, counsel
        depression and death, or an     patients on how to properly
        underdose, leading to poor      take Exalgo, and encourage
        efficacy.                       patients to read the
                                        Medication Guide.
July 15, 2010                                     ISMP MedicationSafetyAlert!   
                                                                                                                               QAA 4
                                                             April – June 2010
                                                ISMP   QuarterlyActionAgenda
Issue               Problem                       Recommendation               Organization              Action Required/     Date
 No.                                                                            Assessment                  Assignment      Completed
                                   Failure to set a volume limit for a magnesium bolus dose leads to harm
(11)     An obstetrician prescribed        Never infuse an IV
        an IV magnesium sulfate bolus     magnesium sulfate bolus dose
        dose of 6 g/30 minutes            from the maintenance
        followed by a continuous          solution unless: 1) The
        infusion of 2 g/hour for a        bolus dose is delivered
        patient in preterm labor. A       using the bolus dose
        nurse obtained a 20 g/500 mL      feature; 2) Separate dose
        bag of magnesium sulfate and      limits are operational for
        programmed the bolus to be        bolus and maintenance doses;
        delivered as a continuous         3) These alerts are
        infusion at 12 g/hour with no     configured as a “hard stop,”
        volume limit. The nurse           and 4) A qualified nurse
        forgot to return to the           remains at the bedside
        patient’s room in 30 minutes      during infusion of the bolus
        to reprogram the rate to 2        dose to monitor the patient
        g/hour. The smart pump did        for signs of magnesium
        not provide a hard stop to        toxicity. If all these
        prevent the administration of     conditions are not met,
        an excessive dose of              administer the bolus dose
        magnesium sulfate.                from a separate container.

                                  Questionable safety with continuous inhalation albuterol infusion set-up
(11)    Albuterol inhalation solution            Avoid this risky
        was added to an IV bag with       practice by only adding the
        tubing that was fit into a        inhalation solution directly
        nebulizer to provide              into a nebulizer cup as
        continuous respiratory            needed.
        therapy to status asthmaticus
        patients. A nurse discovered
        that a patient’s IV
        medications had been infused
        into the IV tubing connected
        to the nebulizer. This
        practice could also lead to
        accidental IV delivery of
        inhalation drugs.
                  The Centers for Medicare & Medicaid Services (CMS) 30-minute rule may result in unintended consequences
(12)     The CMS regulation that           Consider the risks
        requires medications to be        inherent in the workarounds
July 15, 2010                                      ISMP MedicationSafetyAlert!   
                                                                                                                                  QAA 5
                                                             April – June 2010
                                                ISMP   QuarterlyActionAgenda
Issue               Problem                       Recommendation                 Organization           Action Required/     Date
 No.                                                                              Assessment               Assignment      Completed
        administered within 30            that may be taken to comply
        minutes before or after their     with the 30-minute rule,
        scheduled times, may be           and remind nurses that
        causing nurses to drift into      exact timeliness with
        unsafe work habits in order       scheduled medications is
        to meet the rule, such as         frequently less important
        pre-pouring medications, pre-     from a clinical perspective
        charting medication               than making sure the
        administration, and removing      correct patient receives
        medications for multiple          the correct medication.
        patients at the same time.

                            EPINEPHrine pre-filled syringe shortage: Safety concerns with available alternatives
(12)    EPINEPHrine emergency syringes Pharmacists should
        1 mg/10 mL (0.1 mg/mL) are        communicate information
        currently on backorder from       about the shortage and
        the sole manufacturer of this     recommended substitute
        product. Although injectable      products to all potential
        EPINEPHrine is still available areas where EPINEPH-rine
        in other forms, these products emergency syringes are
        may not be safe alternatives.     used. Conserve current
                                          supplies of syringes for
                                          code boxes and emergency
                                          responders where
                                          pharmacists would not be
                                          present during a code.
                                          Review the safety
                                          concerns associated with
                                          the available injectable
                                          products and
                                          corresponding error-
                                          reduction strategies at:
                                   Preventing errors when administering drugs via an enteral feeding tube
(7,     Medication errors related to       A team of nurses,
9,      the administration of drugs       pharmacists, nutritionists,
10,     via an enteral feeding tube       and physicians should
11)     can result due to the             develop protocols for
        incompatibility of                administering drugs through
July 15, 2010                                      ISMP MedicationSafetyAlert!   
                                                                                                                                 QAA 6
                                                             April – June 2010
                                                ISMP   QuarterlyActionAgenda
Issue               Problem                       Recommendation                 Organization           Action Required/     Date
 No.                                                                              Assessment               Assignment      Completed
        administering medications via     enteral feeding tubes that
        a tube, improper preparation      address using appropriate
        of medications, and/or using      dosage forms, preparing
        improper administration           drugs for enteral
        technique. Such errors can        administration,
        lead to an occluded feeding       administering each drug
        tube, reduced drug effect, or     separately, diluting drugs
        drug toxicity.                    as appropriate, and
                                          flushing the feeding tube.
                                          Protocol guidance is
                                          available at:
                      Infusion pump safety issues with Baxter Colleague Volumetric Infusion Pumps and Hospira Symbiq
(9)      FDA has ordered Baxter to        Continue to use Baxter
        recall and destroy all            Colleague pumps while
        Colleague pumps because the       Baxter works with the FDA
        company could not address         to develop a transition
        known safety issues within an plan. For strategies to
        acceptable timeframe. The         mitigate risks with these
                                          pumps, visit:
        Hospira Symbiq infusion pumps
        may not detect air in the
        line if a clinician programs
        the pump to infuse more
                                          8.htm#1. If using Hospira
        volume than in the
                                          Symbiq pumps, review the
        bag/bottle. Also,
                                          safety steps outlined by
        unrestricted flow can occur
                                          the company with your
        with Symbiq, if the cassette
                                          frontline staff
        is removed before the
        cassette carriage is in the
        fully-open position.
                                          cal-bulletin.pdf and
                     The American Association for Respiratory Care (AARC) statement on inhaled medication dosing times
(12)     AARC has a position               Keep on file a copy of the
        statement on inhaled              AARC position statement
        medication dosing times that      (
        differs from the CMS              ition_statements/inhaled_me
July 15, 2010                                      ISMP MedicationSafetyAlert!   
                                                                                                                                 QAA 7
                                                         April – June 2010
                                             ISMP   QuarterlyActionAgenda

Issue              Problem                    Recommendation                 Organization   Action Required/     Date
 No.                                                                          Assessment       Assignment      Completed
        regulation re-quiring           dication_administration.htm
        administration within 30        l) and CMS support language
        minutes of the scheduled        in case state surveyors or
        time. CMS supports the AARC     The Joint Commission
        suggestion of an                question the timeframes for
        administration window that      inhaled medications.
        does not exceed 60 minutes
        before or after the scheduled
        administration time.

July 15, 2010                                   ISMP MedicationSafetyAlert!   
                                                                                                                     QAA 8

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