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.

Preventing Surgical Fires

Surgical fires, while not a common occurrence, are extremely dangerous events that can result in significant patient burns, disabilities and potentially death. Over 200 surgical fires occur each year and most, if not all, are preventable. Surgical fires are caused by combining an ignition source, a fuel and an oxidizer. Ignition sources are things that produce heat, such as electrosurgical units, electrocautery devices, lasers, fiberoptic cables, light sources, drills, saws, and defibrillators. Fuel sources are items that are flammable such as sheets, gowns, hair and drug products including aerosol adhesives, alcohol, degreasers, numbing agents (ethyl chloride), skin preps with alcohol (70% or greater such as ChloraPrep, DuraPrep, Prevail-FX), wound dressings containing tincture of benzoin (with 74-80% alcohol) or collodion, eye lubricants and ointments containing petrolatum (petroleum jelly), and white wax. Oxidizers found in the hospital include oxygen and nitrous oxide.

Fires commonly occur in electrosurgical units that utilize lasers, oxygen-rich atmospheres, and alcohol-based surgical preps. Alcohol-based prep solutions need to dry completely, or fully evaporate, before draping to prevent risk of fire. However, a drape, gauze, or other source may very easily serve as the fuel source as well. One recently reported fire involved the use of Gebauer’s Ethyl Chloride spray, a numbing agent. The label includes a small flame symbol on the front as well as buried text on the side label stating it should never be used near an open flame or electrical cautery equipment. Another report involved the use of Chloraprep One-Step with Tint (2% chlorhexidine gluconate, 70% isopropyl alcohol), an antiseptic surgical skin prep solution. In this case, the solution may have dripped onto the patient’s hair. Drapes and ignition sources such as cautery should be avoided until the solution is completely dry which can take a minimum of three minutes on skin without hair and up to one hour in hair. In addition, the 26 mL applicator should not have been used for this head and neck surgery and the anesthesiologist should have stopped the flow of oxygen while the electrosurgical unit was in use.

The following recommendations may help prevent surgical fires:
  • Inventory all flammable pharmaceutical products (i.e. surgical preps and ointments) used in procedural areas such as operating rooms, physician offices, clinics and ambulatory surgery centers.
  • Evaluate the need for each flammable pharmaceutical product and look for safer alternatives, particularly for topical anesthetics.
  • Raise awareness for all healthcare providers about the dangers of flammable pharmaceutical products and the possibility for burns if the products are used with an ignition source and oxidizer.
  • Utilize auxiliary labeling on packages prior to dispensing to warn about flammability and directions for proper use, particularly if the manufacturers’ warning labels are not prominent.
  • Select appropriately sized prefilled applicators of alcohol-based surgical skin prep solutions for the area to be covered to reduce excess prep.
  • Avoid pooling, spilling or wicking of flammable skin prep during or after application.
  • Ensure the skin prep has adequate time to dry before applying drapes or surgical barriers or beginning the procedure. Most alcohol-based skin preps need at least three minutes to dry. If applied to hairy skin or body folds, it may take up to one hour to dry. Protect the patient’s hair from alcohol-containing solutions. Include drying times on safety checklists to enhance communication between the surgical team.
  • Clean up spilled or pooled skin prep agents and remove excess flammable prep solutions or ointments from the room prior to the use of any ignition source. Dispose of unused flammable skin prep properly to decrease risk of fire.
  • Limit the routine use of supplemental oxygen if the patient can maintain a safe oxygen saturation. If the patient cannot maintain a safe oxygen saturation without supplemental oxygen, secure the airway with a laryngeal mask airway or tracheal tube. If open oxygen delivery is needed, administer the minimum concentration required to maintain an appropriate saturation.
  • Contemplate including a “Surgical Fire Risk Assessment Score” to the preoperative time-out process that obligates the surgical team to identify any flammable materials, oxidizers, and ignition sources that will be used during the procedure. The checklist should help assess the risk of a surgical fire and facilitate a plan to reduce risk.
  • Provide annual training including:
    • Information on causes, prevention, and methods to extinguish surgical fires.
    • Directions for use for all flammable surgical skin preps and ointments.
    • Instructions on controlling ignition sources, managing fuels, and minimizing oxygen- and nitrous oxide-enriched settings.
    • Required attendance at an annual training program for all staff who work in procedural areas including nurses, nurse practitioners, surgical assistants, anesthesia providers and physicians.
    • Surgical fire drills after training to assess effectiveness.

Drug Name Stems for DiazePAM Derivatives

DiazePAM derivative drug stems include the suffixes “-azepam,” “-azam,” and “-azolam”. These belong to the benzodiazepine drug class, are often used for procedural sedation, and are usually prescribed to treat anxiety, panic disorders, insomnia, alcohol withdrawal, seizures, and skeletal muscle spasms. Side effects include drowsiness, fatigue, impaired motor coordination, dizziness, confusion, slurred speech, blurred vision, bradycardia, hypotension, and behavioral changes. Alcohol use or other central nervous system (CNS) depressants such as opioids, antipsychotics, hypnotics, muscle relaxants, and anticonvulsants, may increase the risk of side effects. Avoid concomitant use with opioids when possible due to significant risk of sedation, respiratory depression, coma, and death.

When prescribing diazepam derivatives, consider the patient’s age, concomitant medications and variability in potency, onset, duration of action, and elimination half-life. These drugs should only be used as prescribed and patients should be monitored closely. DiazePAM derivatives are on the Beers Criteria Medication List of medications that are inappropriate for older adults due to the high risk of cognitive impairment, falls, and fractures. If use is necessary in an elderly patient, begin with a low dose and increase slowly.
Classified as a controlled substance, diazePAM derivatives are safe and effective when used short-term. Long-term therapy may lead to the development of tolerance, dependence, and potentially addiction or abuse. The list of approved diazePAM derivitives includes: clonazepam (KlonoPIN), diazePAM (Valium, Diastat, AcuDial, Diastat Pediatric), flurazepam, LORazepam (Ativan), oxazepam, temazepam (Restoril), quazepam (Doral), clobazam (Onfi), ALPRAZolam (Xanax, Xanax XR, ALPRAZolam Intensol), estazolam, midazolam and trazolam (Halcion).

Safety Issues

FentaNYL-SUFentanil Confusion
Due to a shortage of fentaNYL in 2001, 2011 and today, hospitals began temporarily stocking SUFentanil. SUFentanil, an opioid analgesic, is about 5 to 10 times more potent than fentaNYL. For example, 50 mcg of fentaNYL is equivalent to 10 mcg of SUFentanil. A 50-mcg dose of SUFentanil given IV could result in overdose, unresponsiveness, and possibly respiratory arrest, requiring intubation. Errors have occurred within the drug dispensing system when “su” was typed into the system and the brand names Sufenta (SUFentanil) and Sublimaze (fentaNYL) were used as the drug mnemonics.

Strategies to reduce mix-ups between these two drugs include:
  • Educating staff on the difference in dosing between these two drugs.
  • Place visual reminders with warnings where these drugs are stored.
  • Avoid using “su” to select either drug within drug dispensing systems.
  • Remove the brand name Sublimaze.
  • Implement guidelines for converting between fentaNYL and SUFentanil that are easily available to staff.
  • Ensure staff conduct an independent double check before administering IV opioids on nursing units.
  • Request that pharmacy prepare doses of SUFentanil when possible.


  1. Institute for Safe Medication Practices. (2018). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

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