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UNIVERSITYOFWASHINGTON
MEDICAL CENTER
UW Medicine
MED SAFETY NEWSLETTER
AUGUST 2007 VOLUME 3, ISSUE 1
Revised PCA Order Sets
The Patient Controlled Analgesia (PCA) order sets sedation scores ≥2. Alterations are NOT permitted
have been revised to incorporate key safety on the primary care service PCA orders. ALL
strategies with the use of PCA. A signature line has current orders for opioids and benzodiazepines are
been added for nursing to document the completion to be discontinued when a patient is started on a
of an independent double check upon initiation of a primary care service PCA. If APS is managing the
PCA order, a change in medication or a change in PCA, all orders for other opioids or
drug concentration. The use of a separate MAR benzodiazepines must be approved by APS. During
form has been implemented to insure access to the PCA, only the PRN medications listed on the PCA
most current PCA order. The sedation score for order sets are to be used to manage side effects.
notification of physicians has been changed to
Patches: What you can’t see can harm patients
Medication errors have been reported involving fatal overdoses when temperature elevations have
transdermal patch delivery systems and have been increased medication release from the system.
associated with patient harm, including death. Exposure of the patch application site to external
Several variables provide opportunities for error. heat sources such as heating pads, electric blankets,
Before applying a new transdermal patch, be sure to and heat lamps should be avoided. Occluding
remove the existing patch because medication often dressings, such as TegadermTM, may also cause a
remains available in the patch even after its temperature increase and therefore, should not be
recommended duration of use. Few people are used to assist in adhering transdermal patches to the
aware that medication patches should be removed application site. Accidental ingestion of trandermal
prior to an MRI. Some patches contain an patches has been reported due to improper disposal.
aluminized backing that can create an electrical Patches should be disposed of by folding the
current during an MRI and cause burns resulting in adhesive sides together and placing in the sharps
tissue damage. At UWMC patients are screened container. (See the Administration of Medications
before undergoing an MRI for the presence of policy in the nursing policy and procedures).
medication patches. Patches have been linked with
Anticoagulation Services is on the Web!
Looking for the most recent guidelines for the these questions and more can be found on the
prevention or treatment of thromboembolism? Anticoagulation Services website at
Wondering when it is safe to anticoagulate your http://www.uwmcacc.org. This website is also
patient who has an epidural? Trying to manage a conveniently linked through the Medical Staff and
patient with suspected heparin induced Patient Care Services websites. It will soon be
thrombocytopenia? Does your patient need a added to the Clinical Toolkit as well.
warfarin teaching booklet in Russian? Answers to
Risk Management/Quality Improvement Work Product
Do Not Place In Medical Record
Confidential Pursuant to Rcw4.24.240-250 & 70.41.200
Report
Smart Pumps Are Not Smart on Their Own
Incorrectly programming IV pumps is one Infusion. Careful attention should be
Medication
of the most common types of medication made to the alerts that arise. If a soft
Errors and
error. IV infusion devices with smart guardrail alert occurs, the pump should be
Adverse Drug
pump technology have dose checking checked for a programming error and the
Reactions!
capabilities to warn clinicians about clinician should verify that the clinical
potentially unsafe drug therapy. UWMC condition requires higher or lower than
implemented the Alaris Smart Pump® usual doses. Hard limit alerts require the
Infusion System on May 22, 2007. This pump to be reprogrammed as it is NOT
technology can only avert potentially appropriate to exceed these limits. If you
Patient Safety Net harmful infusion-related medication errors encounter a condition that encourages
if used properly. Medications should bypassing the dose-checking feature,
A convenient, ALWAYS be infused through the please contact your LPC or Unit Manager.
web-based system GUARDRAILS rather than as a basic
for Incident
Reporting Drug Name Confusion
Confusion resulting from look-alike and the Safe Medication Practices Committee
***************
sound-alike drug names and look-alike maintains a list of drugs with potential for
Allergy Hotline
product packaging can result in potentially name confusion and updates this list
598-0333
harmful medication errors. At UWMC, annually (see Table).
***************
UWMC Look-alike / Sound-alike Drug List
Clonidine (Catapres®) – Clonazepam (Klonopin®)
Upcoming topics
Cisplatin – Carboplatin
HIT Guidelines Celecoxib (Celebrex®) – Citalopram (Celexa®) – Fosphenytoin (Cerebyx®)
Do NOT Crush! Doxorubicin liposomal – Doxorubicin
Daunorubicin liposomal – Daunorubicin
Opioid Potency
Epinephrine - Ephedrine
Hydroxyzine – Hydralazine
Human insulin (Humulin®) – Insulin lispro (Humalog®)
Insulin lispro (Humalog®) – Insulin aspart (Novolog®)
Metformin – Metronidazole
Morphine oral liquid – Morphine concentrate (Roxanol®)
Morphine – Hydromorphone (Dilaudid®)
Oxycodone controlled-release (OxyContin®) – oxycodone
Do you have ideas for Paclitaxel (Taxol®) – Docetaxel (Taxotere®)
future topics you’d like Vinblastine – Vincristine – Vinorelbine
to see in the Med
Safety newsletter? If
so, contact Jackie What’s new from the Institute of Safe Medication Practices?
Biery, Medication HydromorPHONE alert Dangerous Heparin-Insulin Confusion
Safety Pharmacist at Four deaths occurred after patients received a bolus Three states have reported the accidental addition
jsuper@u.washington.edu dose of 2-4mg of hydromorPHONE, with repeated of insulin to infant TPNs instead of heparin. A
doses of 1-4mg. Contributing factors to these verbal order to resume an insulin drip was
The Medication Safety incidents include: lack of practitioner awareness of transcribed as “resume heparin drip”. A patient’s
Newsletter is published what constitutes an equianalgesic dose of central line was flushed with insulin instead of
quarterly by the Safe
Medication Practices hydromorPHONE, as compared to morphine and heparin. The most common factors associated with
Committee of the University confusion between the names hydromorPHONE these mix-ups are: mental slips since both drugs are
of Washington Medical
Center and morphine. HydromorPHONE is five times dosed in units and similar packaging of insulin and
MORE POTENT than morphine. The UWMC heparin.
Chair: Kim Donnelly, R.Ph.
kimdon@u.washington.edu recommend IV starting dose of hydromorPHONE
is 0.5-1mg.
Risk Management/Quality Improvement Work Product
Do Not Place In Medical Record
Confidential Pursuant to Rcw4.24.240-250 & 70.41.200
