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.


Undetected Heparin-Induced Thrombocytopenia

There are many medical devices on the market today that are pre-coated or coated pre-procedure with heparin to prevent the effects that occur when blood reacts with a foreign surface. The effects, which could hinder device performance, include platelet adhesion, platelet activation, fibrin production, thrombus formation, and other inflammatory responses. Examples of devices that are either manually or commercially coated with heparin include: vascular access catheters and guidewires; drainage, re-transfusion, or thermodilution catheters; devices used during cardiopulmonary bypass; oximetry probes; and some vascular stents and grafts.
Small doses of heparin on devices help to prevent occlusion, minimize infection, and prohibit clotting. However, even modest amounts of heparin can cause an immune-mediated response call heparininduced thrombocytopenia (HIT). HIT can result in serious thrombotic events such as deep vein thrombosis, pulmonary embolism, myocardial infarction, thrombotic stroke and limb occlusion, all of which may cause permanent disability and even death. Heparin used in devices may not be documented in the patient’s medical record which could make diagnosis of HIT very difficult.
Health care providers should consider employing the following recommendations to mitigate the risk of patient adverse events due to HIT and other medication reactions:
  • Compile a list of products that may expose patients to heparin or other medications including drug-eluting stents and commercially applied and/or user-applied medication-coated catheters.
  • Establish a notification system when new products are purchased and update the product list. Identify a staff member who will be responsible for updating the list since these products will not go through the pharmacy.
  • Prior to utilizing medication-coated or drug-eluting catheters or devices, ask the patient if they have any allergies or a history of HIT. Document the allergy in the patient’s chart and work with information technology staff to generate an alert if heparin is prescribed (i.e. therapeutic or prophylactic doses).
  • Collaborate with pharmacy and/or electronic health record staff to establish a system to document in the patient’s record any exposure to heparin-coated catheters or guidewires, and/or medication-coated or drug-eluting devices and catheters.
  • Educate staff on the signs and symptoms of an allergic reaction or HIT response, particularly for those caring for patients exposed to medication-coated or drug-eluting devices.
  • Search for hidden sources of medications when symptoms of possible HIT, allergic reaction, or other drug reaction occurs. Work-up patients for HIT who exhibit signs of thrombocytopenia and other risk factors (i.e. decreased platelet count five to 10 days after starting heparin, or sooner if thrombosis occurs).
  • Discontinue all sources of heparin if HIT is suspected or diagnosed, including heparin-coated catheters and heparin flushes.
  • Document adverse reactions and place prominent alerts on the patient’s medical record to warn staff to avoid administration of the culprit medication.
  • Regularly assess the need for medication-coated devices and catheters to reduce unnecessary exposure.


Drug Demonstration Packaging

Xarelto (rivaroxaban) is manufactured with a demonstration starter pack to educate patients on the proper use of the drug prior to discharge from the hospital. It is used by staff to teach patients to take 15 mg tablets twice a day for the first 21 days and then switch to 20 mg tablets once daily on day 22. The demonstration pack looks exactly like the starter pack and the label does not indicate that the product is for demonstration purposes. The only difference is that pictures of the tablets are printed on a carboard insert. It has been reported that a patient mistakenly ingested the cardboard thinking the medication was imbedded into the carboard. Until label changes are made by manufacturers, health care professionals should add auxiliary labels stating “For Demonstration Only” or “For Simulation Only,” and isolate these products from actual medications or solutions.

EPINEPHrine Auto-Injectors

The EPINEPHrine dose for anaphylaxis is 0.2 – 0.5 mg (0.2 – 0.5 mL) of a 1 mg/mL solution, given subcutaneously or intramuscularly (IM), repeated every five to 15 minutes as necessary. While this practice is standard, dosing errors continue to occur when EPINEPHrine is drawn up in a syringe. Too high a dose (1 mg) has been prescribed and the entire contents of a 1 mg/mL ampule or vial has been drawn into a syringe and given by the intravenous (IV) route. One way to prevent dosing errors when treating anaphylaxis is to use EPINEPHrine auto-injectors. While auto-injectors are expensive, more generic options are now available. If your institution continues to use vials or ampules, the pharmacy should provide patient units with an anaphylaxis kit containing 1 mL (1 mg) vials of EPHINEPHrine, syringes, and clear instructions for dosing, preparation and administration. Only syringes marked in mL, not units, should be included. Avoid insulin syringes since those include a subcutaneous needle, which is inadequate to deliver an intramuscular injection. In addition, the markings on the insulin syringe are not volumetric (mL), which may be confusing during an emergency. The safest way to prevent EPINEPHrine errors is to utilize prefilled syringes (auto-injectors) in the emergency response process for anaphylaxis.

Safety Issues

Single-Dose Vials and Drug Shortages
In an effort to conserve drugs that are in short supply, some health care practitioners save single-dose vials after a dose has been withdrawn for a patient. Single dose vials should not be saved. Once opened, they should be discarded. If single-dose vials are left at the bedside, errors in administration may occur.
Ellipta is a Device, Not a Drug
Ellipta is an inhalation delivery device for asthma medications marketed by GlaxoSmithKline. The trade name Ellipta is used in combination with several asthma medications. The following products are currently available:
  • Anoro Ellipta (umeclidinium and vilanterol)
  • Arnuity Ellipta (fluticasone furoate)
  • Breo Ellipta (fluticasone and vilanterol)
  • Incruse Ellipta (umecldinium)

The “Ellipta” trademark may cause confusion when patients and health professionals refer to these products only by Ellipta without including the asthma drug brand name. This may result in the wrong medication added to the patient’s medication history and ultimately errors in the ordering and dispensing process. Ensure staff are educated about the various asthma products that use the Ellipta inhaler as the delivery device, and discourage staff and patients from referring to these new inhalers by the name “Ellipta”.

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

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