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Medication Errors

Cohen, Michael R. ScD, MS, RPH

doi: 10.1097/01.NURSE.0000484028.80994.4c

When using this premixed infusion bag, administer loading doses as directed...beware sketchy bar code placements on drugs

President of the Institute for Safe Medication Practices

The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at, 1-800-FAIL Safe, or Michael R. Cohen is a member of the Nursing2016 editorial board.

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Administer loading doses safely

Aggrastat (tirofiban) is a platelet aggregation inhibitor indicated for patients with non-ST-elevation acute coronary syndromes. It's available in a premixed bag only (see photo). The drug requires a loading dose prior to a maintenance infusion.

The Aggrastat premixed bag has only an exit port, probably to prevent the inappropriate administration of additives. However, the loading dose shouldn't be withdrawn from the premixed bag via this port. Instead, the product labeling instructs clinicians to administer the loading dose directly from the bag at 999 mL/hour, then switch to the maintenance infusion rate. The product insert includes a weight-based dosing table to help clinicians determine how much volume must be infused for the loading dose and the rate of the maintenance infusion.



Some clinicians question the safety of administering a loading dose from the bag, given that not every facility has smart infusion devices that can automatically switch from the loading dose rate to the proper maintenance infusion rate. Another risk is that any infusion pump could be set improperly.

If a pump doesn't have a loading dose feature, it could still be set to administer the loading dose via the volume to be infused (VTBI) feature, then shut off or switched to a keep-vein-open rate. A nurse could be interrupted and forget to immediately change the rate to begin the maintenance infusion. In a worst-case scenario, a pump without a VTBI feature could be manually set to administer a loading dose, requiring a nurse to reprogram the device after the loading dose has been infused. If that step is missed, the entire volume could be infused at the 999 mL/hour loading dose rate.

To avoid medication errors, the manufacturer recommends hanging the bag with a primed infusion set. The required bolus dose should then be drawn from a port on the infusion set tubing with a syringe large enough to accommodate the volume based on patient weight. (For example, the volume for a patient weighing 96 to 104 kg [212 to 229 lbs] would be 50 mL.) The bag tubing should then be clamped and the loading dose given as a bolus over 5 minutes via a Y site close to the patient's venous access site. The tubing should then be unclamped to start the maintenance infusion.

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Sketchy bar code placement

Regranex (becaplermin) gel is a topical human platelet-derived growth factor indicated for treatment of nonhealing lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. This Smith and Nephew product has a bar code that runs across both sides of the tube near where it's crimped, making it nearly impossible to scan properly (see photo). Bar codes can help prevent medication errors, but not if they can't be scanned. Dispensing Regranex in error could be especially hazardous: This product carries a Boxed Warning due to the increased risk of cancer death in patients who use three or more tubes of the product.



The Institute for Safe Medication Practices has asked the manufacturer to run the bar code longitudinally on the tube label to permit it to be scanned. The current configuration may meet FDA requirements for placing a bar code on the label, but the manufacturer needs to ensure its usefulness.

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