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Medication Errors

Cohen, Michael R. ScD, MS, RPH

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doi: 10.1097/01.NURSE.0000444551.88666.9d
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Don't borrow trouble from a traveling library

A nurse needed to administer ciprofloxacin to a patient but couldn't locate the drug in the smart infusion pump's library. A pharmacist noticed that while the pump was the same brand as others used in the hospital, it had been brought into the hospital during a patient transfer from another hospital and didn't have the approved drug library installed. The other hospital's pump looked the same as those in the nurse's hospital with one exception: The other hospital's name appeared in the heading on the digital readout at the top of the screen (see photo). This difference was easily overlooked because the information was outside the main focal area.

These smart pumps from different hospitals look identical except for the digital readout at the top noting their origin.

Because hospitals are likely to have differing drugs, strengths, and/or dosage parameters in their smart pump libraries, the risk of an infusion error is high when pumps from an outside organization are used. If nurses can't find the correct entry in the library, they may override the dose-checking function and infuse the drug without this important safeguard. Fortunately, in this case the source of the problem was found and corrected before any harm was done.

Be alert to the possibility that a pump arriving from another facility may be left behind after the patient is discharged. If pump programming seems to be a problem in a nonemergency situation, stop and investigate. Hospitals should have policies and procedures for staff to follow during patient transfers to ensure that infusion pumps and other equipment are switched as soon as possible and that equipment not belonging to the hospital is removed.

Hospital administration should consider labeling all hospital-owned pumps with the hospital's name. Rental pumps should arrive with a blank library. If it's not blank, the existing library should be removed by bioengineering personnel and the hospital-specific library loaded before use.


A dash of danger

The generic mycophenolate mofetil capsule, an immunosuppressant, is imprinted with only two bars to help identify the product (see photo above). Although this seems to meet minimum Federal standards for imprinting solid oral dosage forms, it's hard to see how this imprint would help anyone quickly identify the drug in an emergency.

The Code of Federal Regulations [CFR Part 206 (a)] states that solid oral dosage forms must be “clearly marked or imprinted with a code imprint that, in conjunction with the product's size, shape, and color, permits the unique identification of a drug product and the manufacturer or distributor of the product.” However, it also states, “inclusion of a letter or number in the imprint, while not required, is encouraged as a more effective means of identification than a symbol or logo by itself.”

The imprinted code on this capsule doesn't clearly identify the drug.

The bars on the capsule seem to meet the CFR's basic requirements but not its intention that the product be easy to identify. ISMP has notified the company (Accord Healthcare) and the FDA about these concerns.


Avoid this fuzzy format

A long-term acute care hospital with a skilled nursing unit often receives patients from acute care hospitals. Staff reports that some electronic medical records list medication times such as “Daily06” or “Daily08” to indicate once-daily dosing at 0600 or 0800. On several occasions, this type of notation was misinterpreted. For example, vancomycin 1,500 mg I.V. “Daily08” was transcribed as vancomycin 1,500 mg every 8 hours for an 83-year-old patient with a serum creatinine of 1.7 mg/dL. The error was caught by a pharmacist calculating the correct dose based on patient parameters before the patient was harmed.

In another case, pantoprazole 40 mg I.V. “Daily06,” meaning once daily at 0600, was transcribed as 40 mg I.V. every 6 hours. A physician caught the error before it reached the patient. Nurses and other clinicians should avoid this ambiguous format if possible, or, if they encounter it, clarify the dosage with the prescriber.

© 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.