Tag: ISMP

  • Prenteral nutrition error [from #ISMP]

    From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

    The big difference between these two is how you order electrolytes; it’s a really big difference.

    The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?
    (more…)

  • 2012 ISMP Med Safety Self Assessment for Oncology now available

    The Institute for Safe Medication Practices (ISMP), ISMP Canada and the International Society of Oncology Pharmacy Practitioners, have launched the 2012 ISMP International Medication Safety Self Assessment for Oncology. The tool is used to “identify a baseline of oncology-related medication practices and opportunities for improvement.” ISMP is asking that any practice setting that administers chemotherapy get an interdisciplinary team together to go through the assessment; hospitals, ambulatory cancer centers, physician office practices, and so on. Once the assessment is completed the information can be submitted anonymously online through June 29, 2012.

    These self assessment tools are kind of cool. ISMP will aggregate the results and your facility can use the information as a measuring stick to compare your facility to others. The Oncology self assesssment tool can be accessed on the websites of all three organizations (www.ismp.org, www.ismpcanada.org, www.isopp.org).

    ISMP has other self assessment tools as well. You can see them all here.

    I went through the Automated Dispensing Cabinets and Bar Coding Assessments when I was still practicing as an Informatics Pharmacists. They’re quite helpful in jumpstarting the thought process.

  • Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

    When I read the headline in the most recent ISMP Medication Safety Alert!Smart pump custom concentrations without hard “low concentration” alerts I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense.

    Failing to employ available dose error-reduction software (DERS) as intended and to heed important clinical alerts are common contributors to these errors. In particular, the misuse of custom concentration options (i.e., user must fill in the concentration) that do not employ a hard (requires reprogramming) minimum concentration limit is a prime example. This issue contributes largely to preventable errors with smart pumps given the counterintuitive, inverse relationship between concentration and volume. More concentrated drugs require less volume to deliver a specified dose; less concentrated drugs require more volume to deliver a specified dose. When using “fill-in-the-blank” custom concentrations, the concentration must be programmed into the pump so it can calculate the volume needed to deliver the prescribed dose. If the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver an underdose. Without a hard minimum concentration limit, the former scenario has led to life-threatening events, such as those described below.

    Here’s a great example from the article that made the light bulb go off in my mind:

    A physician prescribed IV HYDROmorphone 20 mg/100 mL (0.2 mg/mL) to infuse at 2.5 mg/hour. In this hospital, the standard concentration for this infusion was 0.1 mg/mL, so the custom concentration of 0.2 mg/mL had to be entered into the smart pump. The nurse selected the custom concentration option then mistakenly entered 2.5 mg/100 mL as the concentration instead of 20 mg/100 mL. Given the erroneously programmed concentration of 0.025 mg/mL, the pump issued a soft (can be overridden) low concentration alert. The nurse overrode the warning, mistakenly believing the warning was inconsequential. Based on the erroneous concentration, the smart pump infused the drug at a rate of 100 mL/hour, while the intended rate was 12.5 mL/hour. The pump delivered the entire bag of HYDROmorphone 20 mg to the patient in 1 hour.

  • Don’t confuse Durezol and Durasal (S.A.L.A.D.)

    PharmQD: “FDA is alerting pharmacists and other health care professionals of potential injury due to confusion between the FDA-approved eye medicine Durezol (difluprednate ophthalmic emulsion) 0.05% and the unapproved prescription topical wart remover Durasal (salicylic acid) 26%.

    There has been one report of serious injury when a pharmacist mistakenly gave an eye surgery patient Durasal, the salicylic acid–containing wart remover, instead of the prescribed Durezol eye drops. Durezol is approved for treatment of inflammation and pain association with ocular surgery.”

    Seems like I’ve read about this mistake before. Being their typical efficient self, the FDA alert was issued on December 28, 2011, more than three months after ISMP alerted everyone.

    Some things you can do to prevent stuff like this from happening include (taken from a Pharmacy Times article):

    • Include both brand and generic names, along with indication, when prescribing look- or sound-alike drug names.
    • Spell out drug names that have been confused when accepting telephone orders. Require staff to write down the prescription and then perform a read back (and spell back for drugs that are known to cause confusion) of the complete prescription for verification.
    • Assign time to provide counseling to patients and/or caregivers, especially for new prescriptions.

     

  • ISMP launches first self assessment of ADC safety

    ISMP.org: “More than 80% of US hospitals have implemented automated dispensing cabinets (ADCs) as an important part of their drug distribution system, making the evaluation of practices surrounding this technology an essential step in ensuring patient safety. To help meet healthcare organizations’ growing need for assistance in this area, ISMP has introduced the first Medication Safety Self Assessment for Automated Dispensing Cabinets. The assessment contains 12 core elements that support the safe use of ADCs, which are based on guidelines developed by a national forum convened by ISMP comprising practitioners and vendors with expertise in the safe use of ADCs.** Many of the core elements represent system improvements and safeguards that ISMP has recommended in response to analysis of medication errors and problems identified during onsite ISMP consultations with hospitals. ” – ISMP offers some great resources and their self assessments are are a good way to see exactly where you stand against their “standards”. I would encourage every acute care facility using ADCs to complete the survey and submit their data to ISMP, confidentially of course.

  • Problems with barcodes.

    ISMP Medication Safety Alert! May 21, 2009 Vol. 14, Issue 10: “Please let us know if you identify problems bar_barcodewith  a company’s unit dose package barcode. An example of an ARICEPT (donepezil) unit-dose package with a barcode  problem appears in Figure 1 (shown in the PDF version of the newsletter). Note that the labeling material has been applied to the unit-dose package in such a way that tearing the doses apart destroys the barcode! Problems like this are due to inadequate quality control and are by no means isolated to one company. When issues like this occur, staff are forced to take extra steps to maintain the quality of the barcode, or they have to relabel products so they can be scanned at the bedside. This, of course, takes time and also increases the risk of a labeling error. If you send barcode problems to us along with a publishable photo, it will help us remind companies about the need for adequate quality control.”  Fortunately for us we haven’t seen anything like this, yet.