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.

Programming Errors with Heparin Infusions

Continuous intravenous (IV) infusions of heparin administered via smart infusion pumps are subject to programming errors. Recently reported mistakes have resulted in subtherapeutic doses of IV heparin placing patients at risk for thromboembolic complications. Most continuous IV heparin infusions are weight-based, typically start with a bolus dose and then are titrated based on coagulation laboratory tests.
 
Some facilities have implemented interoperability between the electronic health record (EHR) and smart infusion pumps. This functionality enables the infusion orders, which have been reviewed by a pharmacist, to pre-populate the smart infusion pump screen, reducing the risk of manual programming errors. The settings must be confirmed by a nurse prior starting the infusion. The infusion is also automatically documented in the EHR. However, errors were made in patient units where interoperability was not instituted such as the emergency department (ED) and surgical/procedural areas.
 
The primary error has occurred when a nurse selected “non-weight based” instead of “weight based” on the initial pump screen. For example, the pump was programmed to deliver only 12 units per hour for an 80 kg patient who should have received 12 units per kg per hour, or 960 units per hour. The dose error-reduction system (DERS) was initiated and the smart pump issued a soft low-dose alert, however this was overridden by the nurse. Low-dose alerts cannot be configured as hard stops in certain smart infusion pumps. One small study identified 25 cases in three facilities in which the heparin infusion ran for at least 20 minutes as units per hour instead of units per kg per hour.
 
The following strategies may help reduce the risk of heparin infusion errors:
  • Assess smart infusion pump data (at least quarterly) to investigate whether IV heparin errors have occurred in your facility.
  • Standardize heparin infusions for weight-based dosing only; eliminate non-weight-based dosing for heparin or limit this programming choice to areas where it is absolutely needed.
  • Program a hard stop for low-dose alerts with heparin if your smart infusion pump allows.
    • If your smart pumps do not have this capability, educate your nursing staff on low-dose alerts and the risks of subtherapeutic heparin doses.
    • Low-dose alerts indicate a programming error and should trigger an independent double-check.
    • All overridden smart pump alerts (high- and low-dose limits) should be reviewed.
  • Implement bi-directional smart pump interoperability with the EHR including auto-programming and auto-documentation.
    • Ensure enough smart infusion pumps and channels are available in all clinical areas.
    • Drugs used during a code blue, rapid responses, trauma care, and thrombolytics for stroke patients may be excluded in the ED during management of emergencies.
    • Interoperability may be limited in surgical procedural areas due to workflow restrictions.
  • Require an independent double check of all programming parameters and verification of the patient’s name, patient’s weight, drug (concentration and dose rate), line attachment, and dose-based lab values before heparin infusion is started.
    • If a second nurse is not available, have a pharmacist confirm the calculation, dosing, and rate settings.

Drug Name Stem “-calci-”

The drug name stem “calci”, a prefix or infix (inserted in the middle of a drug name), is used to denote vitamin D analog drugs. Vitamin D analogs regulate bone and calcium homeostasis and treat hyperparathyroidism, vitamin D deficiency, calcium deficiency, and psoriasis. There are eight Vitamin D analogs available in the U.S. and two combination products:
  • Calcifediol (Rayaldee): taken orally to prevent hyperparathyroidism associated with chronic kidney disease
  • Calcipotriene (Dovonex, Sorilux): topical to treat psoriasis
  • Calcitriol (systemic) (Rocaltrol): capsule, oral solution and IV solution to prevent hyperparathyroidism associated with chronic kidney disease
  • Calcitriol (topical) (Vectical): ointment to treat psoriasis
  • Cholecalciferol (Vitamin D3, over the counter [OTC]): taken orally to treat Vitamin D deficiency
  • Doxercalciferol (Hectorol):  oral and IV solution to treat Vitamin D deficiency
  • Ergocalciferol (Clacidol [OTC], Calciferol [OTC], Drisdol, Ergocal): taken orally to treat Vitamin D deficiency
  • Paricalcitol (Zemplar): oral and IV solution to prevent hyperparathyroidism associated with chronic kidney disease
  • Cholecalciferol and alendronate (Fosamax Plus D): taken orally to treat osteoporosis in postmenopausal women and increase bone mass in men with osteoporosis
  • Calcipotriene and betamethasone (Enstilar, Taclonex): topical form to treat psoriasis
Excessive amounts of drugs taken to treat vitamin D deficiency can lead to toxicity – signs include nausea, vomiting, loss of appetite, constipation, dehydration, fatigue, irritability, confusion, weakness, and weight loss. Patients using topical products should avoid sunlight, use sunscreen and wear protective clothing and eyewear. Drugs used to treat hyperparathyroidism may cause hypercalcemia, digitalis toxicity (in patients taking digoxin), and a change in bone density related to chronic kidney disease. Monitor serum calcium and phosphorus levels as well as parathyroid hormone (PTH). Drug used to treat osteoporosis may cause bone, joint, or muscle pain; osteonecrosis of the jaw; atypical femur fractures; worsening heartburn; and hypocalcemia.
 

Safety Issues

Orange Needle Protection
The B. Braun prefilled heparin (5,000 units/0.5 mL) syringe has an orange safety shield that folds back before removing the needle cap and is designed to be secured over the needle after use. Individual syringes are packaged with a label that does not include instructions to engage the needle protection device. To secure the needle, the clinician must press and click the needle into the shield’s needle track with the shield against a hard surface. This process is not intuitive, and all staff should be instructed on the proper use of the protective device.
 
Verbal Communication

Miscommunication errors are common when information is shared verbally, and the issue is compounded by the use of masks and face shields during the coronavirus pandemic. It is important to state orders clearly and to state the dose in single numbers – for example, “17 units” should be stated as “one-seven units”. Other double-digit doses (i.e. 20, 30, 40 and so on) should be communicated with each digit separately. Verify the order with readback (listener documents what is heard, then reads it back), confirming the order was heard and transcribed correctly.
 
Rapid-acting Insulins

There have been reported errors involving rapid-acting insulins such as Fiasp, Novolog and Novolog’s generic. These are all insulin aspart, however Fiasp has niacinamide which makes it faster acting than Novolog. The issue also exists with Lyumjev, Humalog and the generic for Humalog. These are all insulin lispro, however Lyumjev contains Treprostinil, making it faster acting than Humalog. These products have different onsets of action and cannot be substituted for one another. EHR listings should include the brand name and container labels should include both the brand and generic names. Another suggestion would be to include niacinamide in parentheses with Fiasp listings, and Treprostinil in parentheses for Lyumjev listings. Patients should also be educated on the differences between these insulin products.

Reference:

Institute for Safe Medication Practices. (2020). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices: https://www.ismp.org/nursing/medication-safety-alert-october-2020

Previous issues

2020

2019

September 2020: Avoid Blame December 2019: Confusing Naming Methodologies
August 2020: NRFit November 2019: Speaking Up
July 2020: Education October 2019: Literature Review of Independent Double Checks
June 2020: COVID Related Med Errors September 2019: Safe Injection Practices
May 2020: Leadership During COVID-19 August 2019: Methotrexate Mistakes
April 2020: Infusion Pumps Outside COVID-19 Patient Rooms July 2019: Reducing Risks in Medication Administration
March 2020: COVID-19 June 2019: Independent Double Checks
February 2020: Oxytocin Errors May 2019: Newborn Patient Mixups
January 2020: Reporting Errors to ISMP April 2019: Hefty Subcutaneous Doses
  March 2019: Epidural Antibiotic Mix Up
  February 2019: Criminal Indictment
  January 2019: Confusing Glucometer Results

2018

2017

  December 2017: Ongoing Debate Texting Medical Orders
November: Dangerous IV Push Medication Practices November 2017: Dangerous Injection Practices
October 2018: Tracheostomy Balloon Port October 2017: Medication Safety Assessment
September 2018: Errors in Clinical Education September 2017: Heparin Induced Thrombocytopenia
August 2018: Smart Pump Low Concentration August 2017: Insulin Syringe Issues
July 2018: Ellipta July 2017: Texting and Patient Management
June 2018: Rituxan Subcutaneous vs IV June 2017: Verbal Order Errors
May 2018: Nebulized Medications May 2017: Unsafe Infusions & Injection Practices
April 2018: Surgical Fires April 2017: Generic Medication Names
March 2018: Treating Hyperkalemia With Insulin March 2017: Medication Errors at Home
February 2018: Barcode Errors February 2017: Errors in Irrigation
January 2018: Smartpump Miscommunication January 2017: Use Technology Wisely
  
 

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