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.

Oxytocin Errors

Intravenous (IV) oxytocin is often used to induce, stimulate or increase labor during delivery. In the postpartum phase, IV oxytocin generates uterine contractions to help deliver the placenta and to control postpartum bleeding or hemorrhage. However, errors in oxytocin administration can cause excessive stimulation of the uterus which can result in fetal distress, an emergency cesarean section, uterine rupture as well as maternal, fetal or neonatal death.

The following table summarizes common causes of oxytocin errors and strategies to prevent them.
Selection of the wrong drug in order entry systems, particularly when searching using only 3 letters “PIT”, “OXY” or “OXY10” could bring up Pitressin instead of Pitocin (brand name for oxytocin) and oxycontin (oxycodone).
  • Increase the number of letters required (minimum of five) for drug searches in computer order entry systems. This would facilitate only one drug name appearing in the results.
  • Require prescribers to include the indication for the drug on all orders.
  • Utilize standard order sets including administration requirements, patient monitoring, treatment of adverse events and other safety measures.
Confusion with drugs packaged in look-alike vials such as ondansetron (4 mg/2 mL) which is distributed in clear vials with green caps similar to oxytocin. These drugs are also stored alphabetically in close proximity to one another on pharmacy shelves.
  • Assess vial/infusion bag packaging prior to use (or purchase) to ensure they do not resemble other vials or bags currently in use.
  • Check that the label is clear regarding the amount of drug per total volume.
  • If there are medications with similar packaging, and the drug cannot be purchased from a different manufacturer, use auxiliary labeling on all vials, bags, bins, and warn users about the risk.
  • Store look-alike drugs in separate pharmacy and patient care storage locations.
  • Utilize barcode scanning.
Look-alike drug names such as Pitressin (the generic of vasopressin), has been discontinued but may still be found in some order entry systems. Verbal orders for Pitressin have been misheard as Pitocin.
  • Remove outdated brand names, including Pitressin, from computer order entry systems.
  • Avoid using abbreviations such as “PIT” for either Pitocin or Pitressin or “OXY” for oxytocin or oxycodone/oxycontin.
  • Avoid using verbal orders except in emergency cases or under sterile conditions.
Oxytocin infusions may be prepared on patient care units which may result in sterility errors.
Issues arise when not labeled clearly, completely, and accurately.
Errors may also arise when oxytocin is left at the bedside for future use and then accidentally administered.
  • Request pharmacy to provide ready-to-use IV bags of oxytocin that are labeled on both sides of the bag.
  • Do not bring medications to the patient’s bedside until prescribed or needed.
  • If oxytocin must be prepared at the bedside in an emergency, require a double check of the infusion bag and use preprinted labels.
IV line mix-ups and misconnections to the incorrect infusion pump can result in errors. Causes include:
  • Multiple IV lines
  • Chaotic work environment
  • Understaffing/heavy workload
  • Not tracing IV lines
  • Inexperienced Staff
  • Distractions
  • Utilize smart infusion pumps with a dose error-reduction system. Smart pumps that communicate with electronic health records can potentially decrease programming errors.
  • Label oxytocin IV tubing above the injection port closest to the patient as well as just above the pump.
  • Trace the IV from the infusion bag to the pump and from the pump to the patient.
  • Use independent double checks to verify the setup of IV lines.
Infusion bag mix-ups between oxytocin and hydrating fluids or magnesium infusion. Failure to scan the barcode on the infusion bag due to urgency is a contributing factor.
  • Require barcode scanning on oxytocin vials and infusion bags before preparing, dispensing, stocking, and administration.
Inconsistency in terminology used to indicate oxytocin infusion rate in the order, medication administration record or pump library.
  • Concentration is expressed as milliunits per milliliter (mL) or units per liter.
  • Infusion rate is expressed as the amount of drug (milliunits/minute) and as the volume of solution to be infused (mL/hour).
The various terminologies can lead to infusion pump programming errors.
  • Standardize the concentration and bag size for both antepartum and postpartum oxytocin infusions (i.e. 30 units of oxytocin in 500 mL of Lactated Ringer’s).
  • Standardize how oxytocin doses, concentrations, and rates are communicated. Document oxytocin infusion orders by dose rate (i.e. milliunits/minute) to decrease possibility of misunderstanding.
  • Coordinate oxytocin dosing units and concentration with the smart pump dose error-reduction system.
Accidental bolus from residual drug (up to 10 mL) left in IV tubing. Drug can also accumulate in dead spaces of  needleless ports and stopcocks.
  • When oxytocin is discontinued, remove and dispose of any unused portion of the infusion and change the IV line to ensure no residual oxytocin is left in the tubing.
Unclear or incomplete communication and documentation during transitions of care can lead to mistakes.
  • Institute clear communication and documentation procedures.
  • Use standardized strategies and tools during transitions of care.

Drug Stem Name “-afil”

Phosphodiesterase type 5 (PDE5) inhibitors with vasodilator action are typically named with the suffix “-afil”. This class of drugs blocks PDE5 which results in relaxation of the blood vessels and increased circulation to the penile tissue and lungs. These medications are used to treat erectile dysfunction in men, benign prostatic hyperplasia (BPH) with or without erectile dysfunction, and pulmonary arterial hypertension in adults. Four PDE5 inhibitors are currently available in oral tablet, powder for oral suspension, and intravenous (IV) injection.
  • Avanafil (Stendra) – (tablets) to treat erectile dysfunction
  • Sildenafil (Revatio, Viagra) – (tablet, powder for oral suspension and IV) to treat erectile dysfunction; pulmonary arterial hypertension
  • Tadalafil (Adcirca, Alyq, Cialis) – (tablets) to treat erectile dysfunction; BPH; pulmonary arterial hypertension
  • Vardenafil (Levitra, Staxyn) – (tablets) to treat erectile dysfunction
  • For erectile dysfunction, medications are taken 15 minutes to 4 hours, as needed, prior to sexual activity. Each has a different onset of action, half-life, and duration of activity to consider.
  • For pulmonary arterial hypertension, take either once daily (tadalafil) or three times daily (sildenafil).
  • All may be taken with or without food, however high-fat foods may delay absorption.
Side effects include headache, facial flushing, nasal congestion, dyspepsia, and dizziness. Serious adverse effects include prolonged erection (lasting more than four hours), priapism (painful erection lasting more than six hours), vision changes/loss, and hearing loss.

Drug contraindications and warnings include:
  • Avoid concurrent use with nitrates and guanylate cyclase (GC) stimulators as PDE5 inhibitors will increase their hypotensive effects.
  • Use cautiously with antihypertensive medications, particularly alpha-blockers, as PDE5 inhibitors may cause orthostatic hypotension.
  • Carefully evaluate your patient’s cardiac status prior to starting PDE5 inhibitors.

Safety Issues

Antiretroviral Abbreviations
Antiretroviral drugs are often given abbreviations that can cause confusion. For example, Pifeltro (doravirine), typically abbreviated as DOR, is used to treat human immunodeficiency virus (HIV) infection. Prescribers have erroneously selected Dovato (dolutegravir and lamivudine), abbreviated DOV. Both drugs are taken once daily, are available in one strength and are used to treat HIV infection. Confusion can also occur with other antiretrovirals such as tenofovir alafenamide (TAF) and tenofovir disoproxil fumarate (TDF). Avoid using abbreviations and assess your institution’s order entry system, clinical guidelines and electronic medication administration record to ensure abbreviations for antiretroviral medications are not automatically included in the drug name fields. As stated above, a minimum of five letters should be required for all drug searches in order entry systems to limit the results and reduce risk of errors.

Institute for Safe Medication Practices. (2019). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices: 

Previous issues



January 2020: Reporting Errors to ISMP December 2019: Confusing Naming Methodologies
  November 2019: Speaking Up
  October 2019: Literature Review of Independent Double Checks
  September 2019: Safe Injection Practices
  August 2019: Methotrexate Mistakes
  July 2019: Reducing Risks in Medication Administration
  June 2019: Independent Double Checks
  May 2019: Newborn Patient Mixups
  April 2019: Hefty Subcutaneous Doses
  March 2019: Epidural Antibiotic Mix Up
  February 2019: Criminal Indictment
  January 2019: Confusing Glucometer Results



  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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