Medication Errors

Medication safety is a top priority for nurses and avoiding medication errors is critical. Find out what medication errors have recently been reported to the Institute for Safe Medication Practices (ISMP) and learn recommendations for best practices to help avoid these errors.


Generic Medication Nomenclature

A generic drug is the same, or bioequivalent to a brand name drug in dose, strength, route of administration, quality and indicated use.1 Through training and experience, clinicians can develop an ability to identify the therapeutic class of a drug based on its generic name. How exactly do drugs get their names? The generic drug naming process utilizes standard stems or prefixes, suffixes, and roots to identify the pharmacologic property, the chemical structure of the medication, or both.2 The United States Adopted Names (USAN) Council is responsible for choosing simple, informative, and unique generic drug names based on pharmacologic or chemical relationships.2 Knowing the stem can help clinicians determine the drug class, potential indications and effects of an unfamiliar drug.
A few examples of drug stems are:
  • -olol: a suffix for beta blockers which include atenolol, bisoprolol, esmolol, metoprolol, and propranolol. These drugs share similar properties and treat conditions such as heart failure, cardiac arrhythmias and hypertension.
  • -oxetine: a suffix for antidepressants such as fluoxetine, vortioxetine, and paroxetine.
  • -cillin: a suffix for penicillin antibiotics such as amoxicillin, ampicillin, and flucloxacillin.
  • -praxole: a suffix for proton pump inhibitors (PPI) such as esomeprazole, pantoprazole, lansoprazole and omeprazole which reduce the production of acid in the stomach.
There are many exceptions to this general rule. For example, ARIPiprazole contains the -prazole drug stem, which as stated above, is typically associated with PPIs. However, ARIPiprazole is an antipsychotic medication. While drug stems may provide clues about a drug and its action, healthcare practitioners should review drug information for all unfamiliar medications prior to prescribing, dispensing or administering them to patients.2
There are hundreds of drug stems with multiple subgroups and new stems are constantly being created for recently approved medications.2 For practitioners who have not been instructed to recognize the generic stems, classifying drugs into categories and recognizing mechanisms of action, indications and adverse events can be a challenge. Instruction should be provided to all clinicians on the stems associated with the most common drugs administered and for those drugs used to treat chronic conditions. Education should include the clinical effects and typical adverse effects for each drug class.

Safety Issues

Chlorhexidine and Lidocaine Oral Solution Mix-Up
Hi-Tech Pharmacal produces chlorhexidine gluconate oral rinse mouthwash as well as lidocaine hydrochloride oral topical solution 2%. The size and shape of the unit dose cup container as well as the label text color and barcode for both medications are very similar and mix-ups have been reported. If lidocaine is given instead of chlorhexidine, the anesthetic in the lidocaine could affect the gag reflex and the patient’s ability to swallow. A potential adverse effect of topical chlorhexidine is a rare but serious allergic reaction. Hi-Tech Pharmacal is currently the only manufacturer of these products. Until the company makes changes to these labels, you should work with your pharmacy to use additional labels on these containers to differentiate the two. Another strategy would be to purchase one product in bulk and repackage the unit doses before dispensing. Barcode scanning systems may also help reduce errors.
IVFE confused with IV iron (IVFe)
IVFE, an abbreviation used for IV fat emulsion has been confused with IV iron (IVFe). IVFE is an old term that had been used in documentation by the American Society for Parenteral and Enteral Nutrition (ASPEN). The term was also used by the US Food and Drug Administration (FDA) to describe oil-in-water emulsions for intravenous administration. The FDA changed the term to the US Pharmacopeia term, lipid injectable emulsion, abbreviated ILE. Healthcare professionals should now avoid using the abbreviation IVFE to prevent confusion with intravenous iron (IVFe).
Home Infusion Overdose
Ambulatory pump management can be very challenging for patients and their family members in the home environment. Prior to discharge, the patient and family members should have a thorough understanding of how the pump works, what to expect over the course of treatment, infusion rates, how long the infusion should last, how much should be left in the container each day, and importance of reporting any incidents to their healthcare provider if the medication finishes sooner than anticipated. Educating your patients on these critical issues can help prevent serious adverse events and overdose.
Autocover versus Standard Insulin Pens
The NovoFine Autocover disposable safety needle system is a type of insulin pen utilized in many hospitals. With this needle system, the user must hold the outer cover of the needle system while it is screwed onto the insulin pen. The outer cover is then removed, leaving a plastic needle shield that covers the needle. When the device is held against the skin, the needle shield retracts, allowing the needle to puncture the skin and the insulin is injected once the button is pressed. Upon injection completion, the shield slides back over the needle and locks into place so that the needle cannot be used again. This is different from standard insulin pen needles that do not employ a needle shield. Instead, the standard needle includes a needle cap that must be removed prior to injection. These needle systems look very similar. Patients who are more familiar with the Autocover could mistake the standard needle cap as the shield and expect it to retract. If the second cover is not removed, they may not receive the appropriate dose of insulin, if any at all. Patients should be educated on the two types of needle systems available. If they use the standard needles, they should be instructed to remove both caps. All hospital staff should verify which needle the patient will be using at home and be sure to provide training on that device prior to discharge. If blood glucose levels run high after injection, the patient should be taught to contact their diabetes educator, pharmacist, or healthcare provider immediately. They should then be re-educated on proper injection technique.

  1. Food and Drug Administration (FDA). (2017). Understanding Generic Drugs. Retrieved from The Food and Drug Administration:
  2. Institute for Safe Medication Practices. (2017). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

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