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.

Barcode Scanning Errors

There are different types of barcodes utilized on products and medications. A linear (1 dimensional) barcode encodes the national drug code (NDC) number. A 2D (2 dimensional) data matrix barcode encodes the NDC, lot number, and expiration date. Most scanners can read both linear and 2D barcodes. Another type of barcode is the Quick Response (QR) code, which is a type of 2D code used to access product information, but it is not used for automated product identification purposes. Over-the-counter (OTC) products must include a Universal Product Code (UPC), a linear barcode that scanners and some QR code readers can analyze. The two types of scanners available are light-based readers for linear barcodes, and image-type readers that can read both linear and 2D barcodes.

The 2004 Title 21 Code of Federal Regulations (CFR), section 201.25, delineates the barcode label requirements. It states that most prescription drugs available in the US must contain a linear barcode that encodes the appropriate NDC number on the product label. The Drug Supply Chain Security Act (DSCSA) of 2014 requires a 2D data matrix barcode on the smallest container for individual sale in addition to a linear barcode. Adding the 2D data matrix barcode to some medication labels has forced linear barcodes to be repositioned. The placement and orientation of barcodes on medications can impact whether they can be read or scanned. If a barcode is positioned in a horizontal orientation around the circumference of a cannister, scanners may not be able to capture the entire barcode due to changes in light reflection, distortion, or angles.

Two barcodes on one label may lead to confusion regarding which barcode should be scanned. For example, the linear barcode on the Flovent HFA inhaler was repositioned from vertical to horizontal around the circumference rendering it unreadable by the scanner. The nurse was forced to scan the 2D data matrix barcode; however, the 2D barcode was not associated with the product in their database, and scanning resulted in several incorrect product matches.

All clinicians should be informed of the DSCSA requirement to include a 2D data matrix barcode on certain product labels, in addition to the linear barcode. Be sure all practitioners know which barcode to scan for verification when preparing, dispensing, and administering the drug. Health care institutions should implement processes to program new medication barcodes into information technology databases and ensure they are linked to the correct product before use. All barcode scanning problems should be reported to the Institute for Safe Medication Practice (ISMP) so that the US Food and Drug Administration (FDA) and manufacturer can be alerted.

Drug Stem “-triptan”

“-Triptan” is a suffix drug stem associated with serotonin (5-HT) receptor agonists that are SUMAtriptan derivatives. Drugs that end in “-triptan” are used to treat migraine headaches (with and without aura) and to treat cluster headaches. The medications are most effective when given early in an attack and should only be administered to patients at the first sign of an attack if there is a clear diagnosis of migraine or cluster headaches. Triptans do not prevent migraine or cluster headache attacks.

There are seven 5-HT receptor agonists available in the U.S. as oral tablets, oral disintegrating tablets, nasal sprays/powders, or subcutaneous injections. These include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, SUMAtriptan, SUMAtriptan plus naproxen and ZOLMitriptan.

Triptans should be taken as prescribed. If the headache has not resolved in 2 hours or has returned after transient improvement, the dose may be repeated once. Patients should not take more than 2 doses within a 24-hour period. Avoid Triptans in patients with cardiovascular disease (CVD) and use with caution in patients with cardiovascular risk factors.

Avoid concomitant use with monoamine oxidase inhibitors (MAOIs) or ergotamines (i.e. dihydroergotamine [MIGRANAL], ergotamine with caffeine [CAFERGOT, MIGERGOT]. Side effects include: tightness/pressure in the chest, throat, neck and/or jaw; nausea; increase in blood pressure; tachycardia; fatigue, burning sensation over the skin; and paresthesia.

Safety Issues

Simplist syringe with StabilOx canister
The SIMPLIST brand prefilled morphine syringe as well as the DILAUDID (HYDROmorphone) syringe both contain a STABILOX canister within the unit-dose packaging. This canister contains iron oxide, which absorbs oxygen and reduces oxidative degradation to improve stability. The canister should be thrown away once the package is opened. The company is planning to remove these canisters from the packaging. Until that change is made, nurses should be informed to discard the canister.

AuroMedics, levofloxacin, and levETIRAcetam
Some institutions are utilizing premixed IV products to reduce the number of IV solutions that must be mixed in the pharmacy. Many products are available only from one manufacturer. AuroMedics Pharma provides levoFLOX in 250 mg/50 mL, 500 mg/100 mL, and 750 mg/150 mg bags. AuroMedics also provides levetiracetam in 500 mg/100 mL, 1000 mg/100 mL, and 1500 mg/100 mL bags. When the overwrap on these products is removed, the bags look alike which can lead to mix-ups. The font size on the label is very small and difficult to read. The strength is printed on a black background which also makes it hard to read.

Strategies to help prevent mix-ups include:
  • Place pharmacy-applied labels just below the drug name and strengths on premixed bags.
  • Scan the manufacturer’s barcode since scanning a pharmacy label barcode would not detect the wrong drug if the label was placed on the wrong bag.
  • Scan products before dispensing from the pharmacy for individual patients or scan when placed in and removed from an automated dispensing cabinet (ADC).
  • Leave the bags in the overwrap until needed since many of the overwraps use varied colors for different strengths (except for AuroMedics LevETRIAcetam 1,500 and levofloxacin 750 mg which both have an orange overwrap).

VoLumen versus Voluven
VOLUMEN is a barium sulfate suspension for oral administration used to opacify the gastrointestinal tract (GI) in computed tomography. VOLUVEN (tetrastarch, hydroxyethyl starch in sodium chloride) is given intravenously (IV) for fluid resuscitation. While these medications have completely different routes and dose of administration, confusion may still occur since the names are so similar. Clinicians should clarify orders using a standard format and confirm if the patient was scheduled for GI imaging when VOLUMEN is ordered. Administrators should add both medications to the look-alike, sound-alike drug lists and ensure the electronic prescribing system contains an alert when one or the other is ordered.

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

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