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.


Medication Safety Self-Assessment

The Institute for Safe Medication Practices (ISMP) recently launched a new medication safety self-assessment to help hospitals, long-term care facilities, and outpatient facilities evaluate their best practices related to high-alert medications. Organizations that participate in this program will have an opportunity to assess how they are meeting requirements for managing high-alert medications from regulatory and accrediting agencies, such as the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission. The program will also help to identify areas for improvement and help track progress over time.
High-alert medications are drugs that may cause more significant harm to a patient if administered in error. High-alert medication categories include:
  • Neuromuscular Blocking Agents
  • Concentrated Electrolyte Injection
  • Magnesium Sulfate Injection
  • Moderate Sedation in Adults and Children, Minimal Sedation in Children
  • Insulin, Subcutaneous and Intravenous
  • Lipid-Based Medications and Conventional Counterparts
  • Methotrexate for Non-Oncologic Use
  • Chemotherapy, Oral and Parenteral
  • Anticoagulants
  • Neuraxial Opioids and/or Local Anesthetics
  • Opioids
 Organizations that may benefit from this program include hospitals, health systems, long-term care facilities, and some outpatient facilities such as ambulatory surgery centers, emergency/urgent care facilities, oncology clinics, treatment centers, dental surgery centers, endoscopy centers, and diagnostic testing centers. Questions will differ for inpatient and outpatient facilities. An advisory group reviewed all recommendations to ensure that the most critical patient safety practices were included and that these could be implemented in a variety of health care settings. The self-assessment however, is not a minimum standard of practice. Instead, these are innovative, research-based strategies that are not in widespread use today.
The tool may be used independently or organizations may submit their information to ISMP anonymously to receive weighted scores and compare themselves to similar facilities nationally. Scores can be calculated in some instances only if there is full implementation of the item throughout the organization. All information submitted to ISMP is protected, confidential and not shared with any other party, including the federal government.
The assessment is available and can be downloaded from the ISMP website at: Demographic information is collected and organizations must complete the first section of the assessment which covers general high-alert medications. Then, they may focus on sections to evaluate their practices associated with specific high-alert medications. Interdisciplinary teams should work together on the assessment, including staff nurses, physicians, pharmacists, information technology (IT) staff, medication/patient safety officers and risk management or quality improvement staff. If your facility is part of a larger health system, each facility should complete the assessment independently. ISMP will provide comparative reports of the safety practices in US facilities based on data submitted. ISMP will also use the findings to plan educational curriculums, tools, and resources to improve safety when using high-alert medications.

Safety Issues

Do Not Swallow AcipHex Capsules Whole
ACIPHEX SPRINKLE (RABEprazole sodium) delayed-release capsules are used to treat gastroesophageal reflux disease in adults and in children 1 to 11 years old. While packaged in capsule form, it should not be swallowed whole or chewed, nor should it be crushed. The capsules should be opened and the granules sprinkled on a spoonful of soft food or liquid, and administered within 15 minutes of preparation. AcipHex Sprinkle is the only capsule formulation proton pump inhibitor (PPI) that cannot be swallowed whole. Nurses should be aware of the correct administration method as the current auxiliary labels may cause confusion.
Avoid Abbreviating Drug Names
Drug errors occur often and abbreviating drug names only compounds the problem. Avoid abbreviating drug names, particularly when communicating medications verbally. Repeat back (or read back) all verbal orders, stating the full drug name, dose, and dosing units. This is particularly important in fast paced environments such as the emergency department, critical care units and operating rooms where verbal orders can be easily misheard or misinterpreted.
Procainamide 1,000/10 mL Prefilled Syringes – Not to be Used for Bolus Injection
Procainamide hydrochloride injection 1,000 mg/10 mL prefilled syringes should not be used as a bolus injection. These prefilled syringes should only be used to prepare IV infusions. The label includes a printed statement “FOR THE PREPARATION OF I.V. INFUSIONS ONLY”, however the print is small and may be missed. In addition, the syringe has a Luer connector making it appear as a syringe that can be used for bolus injection. An accidental 1 gram bolus dose of procainamide could result in toxicity and possibly death. The Federal Drug Administration recommends products that require further dilution prior to administration should not be packaged in containers that allow for direct administration.
Drug Stem “-ciclovir”
Medications with the suffix “-ciclovir” are antiviral drugs that halt DNA synthesis by inhibiting DNA polymerases, a different mechanism from other antiviral agents. There are six “-ciclorvir” drugs available in the US including: aciclovir or acyclovir, valaciclovir or valACYclovir, ganciclorvir, valGANciclovir, penciclovir and famciclovir. These are used to treat or prevent viral infections caused by herpes simplex virus, varicella zoster virus, and cytomegalovirus (CMV). These will not treat human immunodeficiency virus, influenza or hepatitis. Both ganciclovir and valganciclovir may cause bone marrow suppression. Check your organization’s hazardous drug policy when handling these two medications. Use all “-ciclovir” drugs with caution in patients with impaired renal function (except for topical penciclovir).

  1. Institute for Safe Medication Practices. (2017). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices: 

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