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.

Smart Pump Miscommunication with Electronic Health Records

Smart pumps can now be programmed to communicate with electronic health records (EHRs) allowing information to be shared between the two systems. Known as bidirectional interoperability, orders entered into the computerized provider order entry system (CPOE) may be wirelessly transmitted to populate settings on the smart infusion pump, and then infusion data is wirelessly sent back to the EHR. For example, an infusion order is entered into the CPOE which is sent to the pharmacy for verification and then to the smart pump with a barcode medication administration system, so the pump can be pre-programmed, thus eliminating the need for manual input. To start the infusion, the nurse must scan the barcodes on the patient’s identification band, the drug/infusion, and the pump. Infusion parameters are then wirelessly transmitted from the EHR to the pump for the nurse to verify and accept. Programming information is also transmitted back to the EHR, validated by a nurse, and recorded electronically.

This system may help reduce errors in pump programming. However, there was one report in which a barcode was associated with two different pumps, being used on two different patients. The hospital’s information technology (IT) department accidentally labeled both pumps with the same barcode. While the patients were each receiving the correct infusions, the wrong data was being transmitted back to the EHR. This mismatch problem may also occur if pumps are sent out for repair and are returned with a different barcode than listed on the outside encasement. To link correctly, the barcode on the serial number label on the back of the pump, the IT-applied barcode on the front, and the internal serial number must all match.
If your institution has, or is planning to, implement bidirectional smart infusion pumps, a protocol should be established to include a double check when any serial number is affixed to a pump, especially during initial implementation and during pump repairs.

Drug Library Issues in Programing Smart Pumps

Smart pumps are designed with features such as drug libraries and calculators that provide safe-guards and system checks to help reduce programming errors, however, mistakes may still occur. For example, the “Guardrails Drug” software allows an institution to create customized profiles in which comprehensive lists of drugs and infusions can be created. In one instance, a nurse who was administering PRECEDEX (dexmedetomidine), selected “Guardrail Drugs”, then instead of selecting the drug from the drug library, she selected the “DRUG CALC” (drug calculation) function, which requires additional programming steps, including entry of the “TIME UNITS” in either minutes, hours, or days. The DRUG CALC function is only available after selecting “Guardrail Drugs” on the pump menu. Since there is no indication on the pump screen that the nurse was operating in a non-Guardrail mode, she may have thought she was programming the pump using the drug library and dose error-reduction software (DERS). She then accidentally selected “Min” for minute instead of hour, and the pump did not issue a dose warning. The pump delivered 0.15 mcg/kg/minute (148 mL/hour) instead of the correct dose of 0.15 mcg/kg/hour and rate of infusion of 2.5 mL/hour for several hours. Fortunately, the patient was not harmed.

One strategy to prevent this type of mistake is to limit the use of custom concentrations and the “DRUG CALC” programming function (or other functions that require manual entry of information) to avoid the risk of entering the wrong “TIME UNITS”, drug amount and/or diluent volume. The safety features of DERS are not activated when using “DRUG CALC” (or similar manual entry) function, although this may be helpful when infusing drugs that are not in the library. Educate all staff on proper programming and utilization of the drug library with DERS for all drugs and solutions that have been programmed into the library. Conduct annual competency checks to ensure staff understanding.
When possible, implement a double check of the patient, drug, dose/concentration, line attachment, and pump programming for infusions of high-alert medications that require manual entry of custom concentrations. Monitor compliance with the drug library and the use of custom concentrations or the “DRUG CALC” function.

Safety Issues

DOPamine Label Concentrations
There was a recent report from a hospital that lists two concentrations of DOPamine in their drug library: 400 mg in 250 mL (1,600 mcg/mL) and 1,600 mg in 250 mL (6,400 mcg/mL). The hospital also uses 400 mg in 250 mL IV bags of DOPamine from Hospira. The Hospira bags have “1600” in large print at the top of the label, with mcg/mL in smaller print below it. A nurse in the emergency department picked this bag and selected the 1,600 mg in 250 mL concentration from the pump screen. The drug should have been infused at 5 mcg/kg/minute but was instead infused at a lower rate of 1.25 mcg/kg/minute due to the concentration error (1,600 mg per 250 mL instead of 400 mg per 250 mL). Hospira has been notified of this issue and was asked to change the label to follow USP guidelines where the amount per mL should be in parentheses beneath the total amount of drug in the container (i.e. 400 mg in 250 mL with 1,600 mcg/mL in parentheses below it).

Bicillin L-A Syringe Labeling
The Bicillin L-A syringe has a label that is oriented in a way that makes it difficult for right-handed clinicians to read when holding the syringe by the plunger. Right-handed people need to turn the syringe upside down and hold it by the barrel, which could block part of the label and important information such as the warning “NOT FOR INTRAVENOUSE USE”. The “NOT” may also be obscured by the black plunger making it look like “FOR INTRAVENOUSE USE”. Intravenous administration of the drug, instead of intramuscular, may cause serious adverse events and possibly death. The manufacturer of the drug has been asked to remove this statement and replace it with “For intramuscular (or IM) injection” to decrease confusion.

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

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