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 custom concentrations into smart pumps without hard “low concentration” alerts

While smart pumps are commonly used every day throughout health care institutions, serious programming errors continue to occur. One major mistake that practitioners make is forgetting to set hard stops for minimum concentration limits when programming custom concentrations. Inputting custom concentrations involves selecting a drug from the library and manually entering the concentration (i.e. # mg/# mL). According to a survey conducted by the Institute for Safe Medication Practices (ISMP), almost 50% of the 600 respondents were not sure if their pumps had a hard stop for minimum concentration limits or were completely confused by the question entirely.

There is an inverse relationship between the concentration of drug and volume administered. A more concentrated drug requires less volume to deliver a specific dose. Conversely, less concentrated drugs require more volume to deliver a specific dose. When setting up a smart pump using a custom concentration, the concentration must be programmed into the pump, so the volume needed to deliver the prescribed dose can be calculated by the device. If the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose of medication. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver a low dose. Some pumps may have low concentration alerts; however, these can be overridden.
Errors occur when clinicians:
  • Unnecessarily select a custom concentration option, and then enter the wrong concentration, even when a standard concentration option is available in the pump library.
  • Confuse the dose per hour with the total infusion volume and enter it as the concentration.
  • Leave custom concentration options in the drug library.
  • Ignore soft low concentration alerts or mistaking them for “low dose” alerts.
  • Do not build hard stops for low (minimum) concentration alerts into the smart pump library.
  • Confuse pharmacy labels with drug preparation instructions for the drug concentration.
The following strategies may help reduce errors associated with smart pump custom concentrations:
  • Use one standard concentration for each drug infusion. If more than one is needed, limit the number of concentrations to two, and avoid concentrations that differ by a factor of 10 (i.e. 0.1 mg/mL and 1 mg/mL, and 10 mg/mL).
  • Ensure the pump library utilizes the standard concentration(s) used for each drug. Custom concentrations should only be used in select patient care areas. Remove custom concentration options when a standard concentration for that drug has been established and built into the library.
  • Set hard minimum (low) concentration limits for each drug, particularly high-alert medications, that allows a custom concentration option in the library, to avoid overdose.
  • Educate staff on the inverse relationship between the concentration and the volume, and the significance of low (minimum) concentration alerts.
  • If a custom concentration is necessary, use an auxiliary label to distinguish it from bags or syringes containing a standard concentration.
  • Utilize metric unit dosing (mg/hour, mcg/kg/hour, etc.) in protocols and order sets. Do not accept orders for infusions that include the infusion rate alone (i.e. mL/hour) even if only one standard concentration of the drug is used.
  • Standardized order sets and electronic prescribing systems should allow the prescriber to select only the standard concentration(s) when applicable. Infusion orders should not prescribe the concentration, only the dose (mg/hour, mcg/kg/min) to avoid risk of varying concentrations. If fluid restrictions are required, a “double” or “triple” concentration can be prescribed without specifying the amount of drug per mL.
  • Present the drug and concentration (and infusion rate, if provided) on the medication administration record (MAR) and the infusion label in the same units and sequence required when programming the pump. Include specific instructions for custom concentrations when necessary. Do not include pharmacy technician preparation instructions (i.e. calculations) on the final product label.
  • When hanging a new bottle, bag, or syringe or when changing the infusion rate, require an independent double check using electronic health records (EHR), MAR and other technology (i.e. smart pumps, barcode scanning) to verify and document the following before starting the infusion:
    • Drug/solution
    • Drug concentration
    • Rate of infusion
    • Correct patient
    • Channel selection
    • Line attachment
Note: In titrated medications (i.e. vasopressors), be sure the final infusion rate falls within an expected range.
  • Evaluate the metrics available within smart pumps to identify the frequency of custom concentration use, hard stops for minimum concentrations, soft alert overrides, actions taken in response to these alerts, and other issues that may result in errors. Implement strategies to reduce these identified risks.

Drug name stem “-setron”

“-Setron” is a drug name stem that denotes a group of selective serotonin (5-HT3) receptor antagonists that do not belong in other groups of serotonin receptor antagonists. Most of these medications are used to prevent and/or treat nausea and vomiting caused by radiation, chemotherapy, or surgery. They block the effects of 5-hydroxytrypamine (5-HT3), or serotonin, which activates nerves that transmit vomiting impulses in the stomach and brain. Alosetron (Lotronex) is the only drug in this category used to treat diarrhea-predominant irritable bowel syndrome (IBS) and may reduce pain, abdominal discomfort, and urgency.
Generic Name Brand Name Formulation/Comment
Ondansetron Zofran, Zofran ODT, Zuplenz Tablet, oral film, oral solution, injectable solution
Granisetron Sancuso, Sustol Tablet, injectable solution, transdermal patch
Dolasetron Anzemet Tablet
Palonosetron Aloxi Injectable solution
Alosetron Lotronex Tablets; Indicated to treat diarrhea, irritable bowel syndrome
Fosnetupitant-palonosetron Akynzeo Lyophilized powder for reconstitution
Netupitant-palonosetron Akynzeo Capsules
5-HT3 receptor antagonists have minimal side effects including: headache, dizziness, fatigue, constipation, and diarrhea. These drugs (except for palonosetron) may prolong the QTc interval. Monitor the patient for arrhythmias, hypokalemia, hypomagnesemia before initiating drug therapy.
It is important to instruct the patient to AVOID:
  • Taking more than the prescribed amount.
  • Concurrent use with medications to treat depression and/or migraines which can lead to a lethal condition called serotonin syndrome.
    • selective serotonin reuptake inhibitors (SSRIs)
    • serotonin and norepinephrine reuptake inhibitors (SNRIs)
    • monoamine oxidase inhibitors (MAOIs)
  • Concomitant use with other QTc-prolonging agents and promethazine due to increased risk of cardiac arrhythmias.
  • Apomorphine (anti-Parkinson agent, dopamine agonist) due to increased risk of hypotension and loss of consciousness.

Safety Issue

The abbreviation for the drug alteplase (ACTIVASE) is tPA, which stands for tissue plasminogen activator. This abbreviation has been confused with others such as TNK, used for TNKASE (tenecteplase). More recently, tPA has been confused with TPN (total parenteral nutrition). The ISMP and Food and Drug Administration (FDA) recommend avoiding the use of tPA in all general care areas including protocols, standard order sets, order entry screens, and smart infusion pumps. Prescribers should include the indication when prescribing alteplase, tenecteplase or reteplase. Alteplase is used to manage acute myocardial infarction, ischemic stroke, or pulmonary embolism. Tenecteplase and reteplase are used to manage acute myocardial infarction only. The FDA recommends using alerts during order processing and on MAR screens to remind clinicians to verify the correct indication.
  1. Institute for Safe Medication Practices. (2018). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

More Nursing News Headlines (Pharmacy)...

Powered by