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Medication Errors

Cohen, Michael R. ScD, MS, RPh

Author Information
doi: 10.1097/01.NURSE.0000769880.82566.49
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In Brief


Medication misadventure: Cecostomy vs. gastrostomy

An 8-year-old patient was inadvertently administered acetaminophen, lansoprazole, and sucralfate via cecostomy instead of gastrostomy. She had both a cecostomy and gastrostomy button. Buttons are low-profile devices anchored to the abdominal wall with a balloon and not visible under clothing, whereas cecostomy and gastrostomy tubes extend for several inches and are taped to the abdomen between uses. Common button devices include the Avanos Mic-Key button and the Applied Medical Technology (AMT) MiniONE button.

The patient's cecostomy button was in place to manage baseline constipation and was attached to an extension set for saline flushes at home; the gastrostomy button was not attached to an extension set. When the nurse administered the medications, she used the extension set that was hooked up to the cecostomy. The extension sets look similar, including a medication port and a larger port for fluids and feedings, and none of the medication ports have Luer lock connectors. So, oral syringes and feeding bag tips can push into the ports. Medications are best absorbed in the small intestine rather than the large intestine past the cecum, so medications administered via a cecostomy would not be absorbed very well. The patient's provider was notified, and the nurse was instructed to readminister the medications at two-thirds of the normal dose according to pharmacy recommendations.

As a preventive measure, ENFit extension sets are available for both Mic-Key gastrostomy buttons and AMT devices. To prevent similar confusion, medications may be provided by the pharmacy in ENFit syringes and used with ENFit extension sets. If the cecostomy button had legacy extension tubing, it would not connect with ENFit syringes, thus preventing misconnections and misadministration of medication via the wrong tube. Button devices and ENFit extension tubing are also available for jejunostomies and gastrojejunostomies.


Stop printing bar codes across round surfaces!

A hospital discovered a billing issue with its rabies immune globulin (human) 2 mL vial, KEDRAB (manufactured by Kamada, distributed by Kedrion Biopharma), while auditing their 340B program. They were not receiving the product at the correct 340B contract price because they had “no documented administrations” of it at the hospital. However, the hospital had frequently been reordering the product, so it clearly was being used. The pharmacy researched the problem and found numerous instances of not billing for the medication. The 340B program software links the billing of the doses administered to how much is being used. It turned out that the medication was not being documented on the medication administration record (MAR). Despite nurses thinking the product label scanned, documentation failed because the bar code on the product is printed on the label horizontally on the curve of the round vial, so it could not be completely read by the laser scanner.

The vial is packaged in a carton that has a scannable bar code, but nurses usually discard this after removing the vial, so it is no longer available at the bedside during administration. While not ideal, for now, this pharmacy is asking nurses to hold on to the carton to scan its bar code at the bedside before administering the product, rather than scanning the bar code on the vial. At a minimum, nurses should manually document administration on the MAR if the carton has already been discarded.


ISMP has repeatedly mentioned this problem in the past with bar codes on the labels of round ampules, vials, inhaler canisters, and oral liquid bottles. Linear bar codes on round ampules, vials, inhaler canisters, and oral liquid bottles should only be printed perpendicular to the curve of the container, usually along the edge of the label on one side, rather than horizontally around the curve of the container. Purchasers should avoid products with curved bar codes, when possible, if scanning technology is used during product selection and administration.

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