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ISMP Medication Safety Alert!


Educating the healthcare community about safe medication practices January 2008 Volume 6 Issue 1

Errors with injectable medications:

Unlabeled syringes are surprisingly common!
esearch shows that the blood pressure increased after local
check out! 9999
To reduce risks associated with unla-
incidence of errors with injection of the epinephrine into his beled syringes, consider the following:
injectable medications is limb, initially leading staff to believe he
higher than with other was experiencing malignant hyperther- 9 Prelabeled syringes. Have phar-
forms of medications.1-2 Studies also mia. The error was recognized after the macy dispense ready-to-administer
suggest that half of all harmful drug patient developed ventricular tachycar- injectable products in labeled syringes
errors originate during the administra- dia and pulmonary edema. He fortu- as prescribed for individual patients.
tion phase; of those errors, about two- nately recovered without harm.
thirds involve injectable medications.3-4 9 Prefilled syringes. Use commer-
Last June, the American Nurses cially available, prefilled syringes of med-
Several factors5 increase the risk of Association released the results of an ications, which are already labeled.
errors and patient harm with online survey of more than 1,000 US
injectable medications: nurses about the challenges of label- 9 Commercial labels. Use commer-
Availability of concentrated drugs for ing syringes that contain injectable cially available labels for syringes in all
which further dilutions are required medications.5 The survey revealed drug preparation areas (including radiol-
Complex calculations (e.g., chang- that most (97%) nurses are worried ogy, nuclear medicine, and other areas
ing a dose from mmol to mg) about medication errors, and more where medications are administered).
Requiring multiple manipulations than two-thirds (68%) believe errors Tape is not suitable for labeling syringes.
to prepare the drug (e.g., vial-to- can be reduced with more consistent
syringe transfer, syringe-to-syringe syringe labeling. Nearly half (44%) of 9 Label placement standards.
transfer, dilution, use of a filter) the nurses said they inject medications Follow established guidelines regarding
Reconstitution of powders and drugs via a syringe more than five times each label placement on syringes, including
that require special diluents shift, and one-third (37%) administer specific directions on how to avoid inter-
Use of part of/more than one vial/ injectable medications at least once ference with viewing gradations on the
ampule for a single dose each shift. Just one-third (37%) of syringe barrel and the contents of the
Use of medications that require nurses reported that they always label syringe, or interference with use/
non-standard handling/precautions the syringes they prepare, and one in function of the syringe. Apply the label
(e.g., light protection, inline filter) four (28%) nurses admitted they never directly below gradation lines to ensure
Inadequate/inaccessible drug infor- label syringes they prepare. that the scale and name of the drug and
mation strength/dose are visible. Labels should
Preparing the drug in clinical areas Nurses who responded to the survey be oriented to facilitate viewing when a
instead of the pharmacy, with reported that several factors interfere right-handed person holds the syringe.
limited or absent product labeling. with or prevent routine labeling of
syringes. They noted that labels may: 9 Discard if unlabeled. Discard unla-
Unlabeled syringes are a significant Cover the measurement gradation beled syringes and report the event as a
risk associated with preparation of on the syringe barrel (65%) hazardous condition. No syringe should
injectable products in clinical areas. To Not be suitable for a syringe (55%) leave a nurse’s hand unless it is labeled.
cite one instance, a 15-year-old teen- Impair the ability to check the
ager with a history of malignant hyper- dosage when comparing the medica- NurseAdvise-ERR ® funding for 2008
thermia received the contents of an tion in a syringe with the order (39%) We are very pleased to announce that this
unlabeled syringe that was thought to Make syringes hard to handle (31%) newsletter will again be offered free to US
contain MARCAINE (bupivacaine) Detach from the syringe (30%) hospitals in 2008 through educational
with epinephrine. The syringe actually Make it difficult to attach a syringe to grants from McKesson—our supporter for
contained 30 mL of epinephrine a pump (24%). the past 3 years—as well as a new sup-
1:1,000. The nurse who had drawn the porter, Baxter Healthcare. Please join us in
medication into a syringe had intended To reduce risks associated with thanking our 2008 supporters by sending a
to add it to several bags of normal unlabeled syringes, consider the message to
saline, but she was called away unex- recommendations in check out! in it We will forward all messages to
pectedly and left the unlabeled syringe the right column. appropriate company representatives.
on a tray near the patient. The patient’s References appear at the bottom of page 3.

Supported by educational grants from McKesson and Baxter Healthcare


Page 2 January 2008 Volume 6 Issue 1

ADC survey shows improvements, but risks still prevail

Automated dispensing cabinets
(ADCs)—perhaps more accurately
processes are important to prevent
potentially serious stocking and/or
safety wires
Easily misread abbreviation.
referred to as automated distribu- drug retrieval errors. While these The abbreviations "q am" and
tion cabinets*—were introduced in checks could be performed with bar- "q pm" can be mistaken as 9 am and
the 1980s to help with medication coding, just a quarter (25%) of hospi- 9 pm and should be avoided. Instead,
distribution, storage, security, and tals reported using this technology. precede "am" or "pm" with "daily" (e.g.,
retrieval documentation. Adoption of daily am, daily pm). If "q am and q pm"
this technology started slowly, with Pharmacist review and overrides. are used together, implying the drug
only about half of hospitals using Profiled ADC systems are one of the should be given twice daily, it would be
ADCs in 1999. However, by 2005, most important safety enhancements safest to use "BID am and pm" instead
close to three-quarters of acute care that has evolved in ADCs. This safety of "daily am and pm," since "daily" may
hospitals were using ADCs in their feature provides a direct interface imply once-a-day dosing. Incidentally, an
facilities.1 According to more than between the pharmacy computer and analysis of 30,000 medication errors in
800 respondents to our November ADCs so pharmacists can screen all USP's MedMarx database showed that
2007 survey in the ISMP Medication newly prescribed medications for the most common abbreviation result-
Safety Alert!® and Nurse Advise-ERR® safety before they are removed from ing in a medication error was "qd" for
newsletters, 94% of readers told us the cabinet for administration. This "once daily," accounting for 43.1% of
they use ADCs in their facilities; of screening process helps ensure that all abbreviation-related errors. Other
those, more than half (56%) use the serious drug interactions, dosing prob- abbreviations commonly resulting in
technology as the primary means of lems, cross allergies, or duplicate ther- medication errors were "U" for units,
drug distribution. apy are detected before the medica- "cc" for mL, "MSO4" or "MS" for mor-
tion is available to the nurse for admin- phine sulfate, and decimal errors. All
ADCs can decrease the amount of istration. Some of these potentially but "cc" are on The Joint Commission's
time before a medication is available life-threatening conditions may not be DO NOT USE list for National Patient
on patient care units for administra- picked up without the support of Safety Goal 2B, but "cc" is slated as an
tion, ensure greater security of med- sophisticated software programs that abbreviation for future inclusion.
ications, and capture drug charges are used in the pharmacy. Further,
more efficiently and accurately. ADCs requiring a pharmacist to review the Duragesic-12, not 12.5. A 64-
can also reduce the risk of medication safety of a newly prescribed medica- year-old female patient with breast
errors, but only when specific safe- tion before it is administered to a cancer received a prescription for fen-
guards are consistently in place. When patient ensures an independent tanyl patches 12.5 mcg/hour every 72
compared to data from our 1999 sur- double-check of the medication by hours. The prescription was faxed to
vey on ADCs, it appears that more two highly trained practitioners—a the pharmacy, but due to illegible hand-
organizations are currently employing nurse who knows important informa- writing and a fax transmission, the phar-
these important safeguards. Yet, as the tion about the patient that might not macist missed the decimal point and
highlighted findings below demon- be known by the pharmacist, and a read the prescription as 125 mcg. The
strate, the improvements are incre- pharmacist who knows important medication was dispensed as separate
mental and not as widespread as information about the drug that might 100 mcg and 25 mcg patches, both of
needed to maximize the safety bene- not be known by the nurse. which were applied to the patient's
fits that ADC technology offers. chest. The next day, a different pharma-
In 1999, only 28% of respondents cist recognized the error and contacted
Checking processes. The requirement reported that a pharmacist must verify the physician before the patient was
for a pharmacist to check ADC stock orders before drugs can be removed harmed. DURAGESIC-12 is the brand
medications before they leave the phar- from ADCs; but in 2007, 64% of name of the only fentanyl patch avail-
macy increased from 65% in 1999 to respondents reported adopting this able in a 12.5 mcg/hour strength. The
75% in 2007. No improvement was practice. Interestingly, fewer (56%) intent of the "12" in the drug name is to
seen between 1999 and 2007 regard- frontline nurses reported that pharm- help prevent ten-fold dosing errors
ing verification processes after restock- acy verification always or frequently since confusion between a 12.5 mcg
ing the ADCs; in both years, just 18% occurs before removing medications and a 125 mcg per hour dose could be
of respondents reported that another from ADCs, compared to 72% of fatal. Medical staff should be reminded
person verifies drug placement in the other healthcare professionals, partic- to use the number "12," not "12.5,"
ADC. Requiring another nurse to ularly pharmacists. Further, just 59% when ordering the lower strength
double-check a drug removed from an of 2007 respondents reported that that Duragesic patch. Nurses should be suspi-
ADC via override (before pharmacy all ADCs in their facilities are capable cious of initial doses higher than
review) only increased from 10% in of profiling. 25 mcg/hour unless the patient is
1999 to 29% in 2007. These checking continued on page 3 known to be opiate tolerant.

Page 3 January 2008 Volume 6 Issue 1

ADC survey continued from page 2

Cabinet design. Just 50% of respon- compared with responses from other Special Announcements
dents noted that individual compart- healthcare professionals who com- Free webinar. Please join us on
ments for each drug are always or pleted the survey, frontline nurses January 25 for the first webinar based
frequently available in the ADC reported less satisfaction with ADC on the 2007 Nursing Leadership
cabinets. workflow and reported using more Congress: Leadership Competencies
workarounds to compensate for for Effecting Change. Dale Beatty, RN,
ADC stock. In both 1999 and 2007, workflow problems. MS, Vice President of Northwest Com-
35% of respondents reported that they munity Hospital in IL, and Mary Beth
always or frequently encounter multi- Despite the growing popularity of Navarra-Sirio, RN, MBA, Patient Safety
ple concentrations of medications in ADCs and the benefits this technol- Officer for McKesson, will be discussing
ADCs. In 2007, respondents, particu- ogy offers, few resources exist to leadership core competencies, effective
larly nurses, also reported that they guide healthcare organizations learning mechanisms, management of
encounter fewer ready-to-administer toward best practices and safest use time constraints, and improving patient
medications in ADCs than reported in of this technology. To address this safety through shared governance. For
1999. Almost a quarter (23%) of 2007 deficit, ISMP convened a group of information, visit: http://nursingleader-
respondents reported that non-med- stakeholders in the spring of 2007 to
ications are now being stored in develop ADC practice guidelines.
ADCs, an increase from 15% in 1999. These guidelines (draft) are currently ISMP teleconference. Please join us
posted on the ISMP website at: for our first 2008 teleconference, Safe
Workflow and practice habits. In Use of ADCs: Choosing Safety Over
2007, additional assessment items lFormats/comments/default.asp. Convenience, to be held on January
were added to the ADC survey related The guidelines contain 12 core 30 from 1:30-3:00 pm ET. The speakers
to workflow and practice habits. processes associated with safe ADC will address common errors associated
Almost a third (30%) of frontline use (see Table 1 below). Please be sure with the use of automated dispensing
nurses reported that they always or to review these core processes and cabinets (ADCs) and present new consen-
frequently wait in line to access the make plans to employ as many as pos- sus recommendations designed to improve
ADC, and almost half (48%) reported sible in 2008 to reduce the risk of seri- formulary management, drawer configura-
that the ADCs are not located in areas ous errors associated with ADC use. tion, restocking procedures, system over-
free from distractions. Only two-thirds rides, and medication withdrawal and trans-
(69%) of frontline nurses reported that *Professional licensing boards have suggested call- port. To register, visit:
ing ADCs automated distribution cabinets since
they always or frequently remove just pharmacists, not nurses, dispense medications. tional/teleconferences.asp.
one patient's medications at a time,
implying that multiple patients' med- Reference: 1. Pedersen CA, Schneider PJ, Free CE Credit. One hour of continuing
Scheckelhoff DJ. ASHP national survey of pharm-
ications are removed a third of the acy practice in hospital settings: dispensing and education (CE) credit is now available for
time—a practice that is known to lead administration. AM J Health Syst Pharm. 2006; the July-December 2007 issues of Nurse
to drug administration errors. When 63:327-45. Advise-ERR® at:
Table 1: Twelve Core Processes Associated with ADC Use
1. Provide ideal environmental conditions for the use of ADCs References from page 1: 1) Taxis K, Barber N.
Ethnographic study of the incidence and severity of intra-
2. Ensure ADC system security
venous medicine errors. Br Med J. 2003;326:684-7. 2)
3. Use pharmacy-profiled ADCs Cousins DH, et al. Medication errors in intravenous
4. Identify information that should appear on the ADC screen medicine preparation and administration: a multicentre
5. Select and maintain proper ADC inventory audit in the UK, Germany and France. Qual Saf Health
6. Select appropriate ADC configuration (e.g., lidded compartments vs. matrix drawers) Care. 2005;14:190-5. 3) Bates D, et al. The cost of
adverse events in hospitalized patients. JAMA.
7. Define and implement safe ADC restocking processes
1997;227:307-11. 4) Bates DW, Cullen DJ, Laird N.
8. Develop procedures to ensure the accurate withdrawal of medications from the ADC Incidence of adverse drug events and potential adverse
9. Establish strict criteria for ADC system overrides drug events: implications for prevention. JAMA.
10. Standardize processes for transporting medications from the ADC to the patient’s bedside 1995;274(1):29-34. 5) American Nurses Association.
Medication errors and syringe safety are top concerns for
11. Eliminate the process for returning medications directly to their original ADC location nurses according to a new national study. Press release:
12. Provide staff education and competency validation June 18, 2007. Accessed at:
Full results of the survey can be found at: aResources/PressReleases/2007/SyringeSafetyStudy.aspx
ISMP Medication Safety Alert! Nurse Advise-ERR (ISSN 1550-6304) ©2008 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce
material for internal newsletters or communications. Other reproduction is prohibited without written permission. Unless noted, published errors were received through the USP-
ISMP Medication Errors Reporting Program. Editors: Judy Smetzer, RN, BSN, FISMP; Charlotte Huber, RN, MSN; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD.
ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Tel. 215-947-7797; Fax 215-914-1492;
Report medication errors to ISMP at 1-800-FAIL-SAF(E).