Incorrect lidocaine infusion option selected in smart pump drug library
An anesthesiologist inadvertently administered lidocaine at a rate of 30 mg/minute instead of 30 mcg/kg/minute. The patient then received 1,500 mg over 50 minutes rather than the intended dose of 85 mg. When the programming error was discovered, the patient was immediately treated with a lipid rescue infusion (http://www.ismp.org/ext/1082). No complications occurred as a result of the overdose.
In preparation for interoperability with the electronic health record (EHR), the organization's smart pump team had recently merged a separate profile for anesthesia providers with the main drug library. To prepare the anesthesia team for the transition, the smart pump team provided educational modules and live demonstrations on how to use the pump. After the smart pump team released the single-profile drug library, the anesthesiologist selected the anesthesia mode and searched the letters "K to O" for lidocaine, but only saw one option on the screen.
The anesthesiologist failed to scroll to the next screen, where additional options were located. These options included "lidocaine ANES" with a dose rate of mcg/kg/minute intended for perioperative infusions. The "lidocaine ANES" option had a soft maximum dose alert of 35 mcg/kg/minute without a hard maximum dose limit. However, the lidocaine option that the anesthesiologist inadvertently selected was intended for ventricular dysrhythmias with a dose rate of mg/minute. Although this option had a hard maximum limit (5.5 mg/minute), the hard stop feature was not available since the pump was running in anesthesia mode. This feature was unable to protect end users from a potentially catastrophic programming error.
When the anesthesiologist programmed a dose of "30," the soft maximum alert (greater than 5 mg/minute) fired, but the anesthesiologist overrode the warning without noticing the mg/minute dose rate.
Consider the following resources and recommendations to prevent programming errors when using smart pump drug libraries:
* Standardize dose/dose-rate nomenclature and dosing limits for I.V. medications and fluids (http://www.ismp.org/node/972).
* Ensure drug library content in the EHR is consistent with the drug information and nomenclature, such as the drug name, dosing units, and dosing rate (http://www.ismp.org/node/160).
* Utilize smart infusion pump technology with an engaged dose error-reduction system in all perioperative and procedural settings, including intraoperatively by anesthesia providers and other practitioners (http://www.ismp.org/node/31601).
* Limit the use of smart pumps in "anesthesia mode," which reduces all hard stops to soft stops. Hard stops can serve as a forcing function and dramatically reduce the incidence of incorrect infusion pump programming (http://www.ismp.org/node/14839).
Enfamil multivitamin look-alike label concern
A pharmacy technician identified a look-alike labeling concern upon receiving a shipment of Enfamil POLY-VI-SOL MULTIVITAMIN DROPS (NDC: 00087-0402-03) and POLYVI-SOL MULTIVITAMIN & IRON DROPS (NDC: 00087-0405-01) manufactured by Mead Johnson & Company. The product containers are the same shape and size (50 mL), and the solutions are nearly the same color. Despite a recent labeling design change, the formulation information remains small, and the nonclinically relevant text has become more prominent (see Labels on bottles). Similarly, the drug name and ingredients on the carton's primary display panels are much less prominent than the "Brain & Body" and "Growth & Immune Health" wording (see Enfamil multivitamin cartons). Furthermore, both products lack a bar code on the immediate container label. The manufacturer has been asked to better differentiate these products and to display the ingredient information more prominently. The US FDA has also been notified of this issue