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.

Is Education Enough?

Education is a necessary component of every clinicians’ training and provides each with the knowledge they need to perform their jobs. However, education is considered one of the least effective approaches to improve patient safety and reduce risk. Quality improvement and risk management strategies that are the most effective are those that prevent practitioners from making mistakes. Education, when used alone, cannot accomplish this goal for the following reasons:
  • Education relies on human memory and does not guarantee that the information has been learned, will be applied correctly or lead to the desired skills. Several factors impact the educational process:
    • Inattention inhibits learning
    • Individuals have different learning styles
    • Knowledge and skills diminish or are forgotten over time, particularly if not utilized
    • New information may conflict with prior knowledge
    • Lack of memory cues to retrieve information
  • Education does not reduce human errors caused by forgetfulness, preoccupation, distractibility or transposing numbers unless a knowledge deficit is uncovered. Examples of system designs that were developed to prevent these types of errors include drug name searches in automated drug cabinets that avoid look-alike product names in drop-down menus or prompts that require the clinician to check patient allergies or expiration dates.
  • Education will not alter habits or unsafe practices. Risky behaviors are developed when clinicians attempt to work around system failures and are typically not associated with a knowledge deficit, but instead an inability to recognize risk associated with the action. Systems should be designed to reward good habits and behaviors.
  • Education attempts to change human reliability but does not change system reliability. It is virtually impossible to make humans reliable all of the time.
  • Education requires recurrent repetition due to staff turnover and student rotations.
Education, used alone, is a weak strategy to improve the quality of patient care. Several high-level risk-reduction strategies that enhance system reliability must be combined with education to increase safety and decrease errors.


There has been an increased use of neuromuscular blocking agents and propofol to care for critically ill COVID-19 patients, which has led to a shortage of both agents. To help alleviate this shortage, the U.S. Food and Drug Administration (FDA) has allowed the following:
  1. Manufacturers of vecuronium (lyophilized powder, 10 mg and 20 mg per vial) and rocuronium (50 mg/5 mL, 100 mg/10 mL) will be allowed to produce these drugs without the vial cap and seal containing the statement “Warning: Paralyzing Agent”. The products will have the same U.S. container and labels with a paralyzing agent warning statement. However, without the cap warning, the vials look like other medications with a similar vial size and cap color. To prevent medication mix-ups, the following strategies are recommended:
    1. Communicate this change to intensive care unit (ICU), perioperative, labor and deliver unit, emergency department, and ambulatory surgery center staff.
    2. Pharmacy should affix an auxiliary label noting “Warning: Paralyzing Agent” to the vial cap.
    3. Assess where and how these drugs will be stored; don’t store the vials in a manner in which only the caps are visible; be sure the vials are lying down so labels can be seen, particularly on low shelves in a refrigerator.
    4. Emphasize the importance of barcode scanning before administration.
    5. Employ independent double checks.
  2. An emergency use authorization (EUA) was issued to allow importation of Propoven 2% (propofol 20 mg per mL) emulsion in 100 mL vials. This drug is limited to maintaining sedation via continuous infusion in patients 16 an older who require mechanical ventilation in ICUs during the COVID-19 pandemic. Propoven 2% contains double concentration (20 mg/mL) of Diprivan which is 1% (10 mg/mL) emulsion.
    1. Communicate this to critical care prescribers, nurses in critical care units, and anesthesia providers.
    2. Utilize alert stickers, wall charts and fact sheets, developed by the manufacturer, that highlight the difference between Diprivan 1% and Propoven 2%.
    3. Update electronic drug databases and smart infusion pump drug libraries with the drug and dosing.
    4. Educate staff that the infusion rate for Propoven 2% is half of the typical infusion rate for propofol 1%.
    5. Ensure the barcode scanning system will provide the correct information when Propoven 2% is scanned.


Vincristine Labeling
The FDA requested a change to the label of vincristine sulfate injection to state: To reduce the potential for fatal medication errors due to incorrect route of administration, vincristine sulfate injection should be diluted in a flexible container and prominently labeled as indicated “FOR INTRAVENOUS USE ONLY – FATAL IF GIVEN BY OTHER ROUTES.” Over 130 deaths occurred due to accidental intrathecal injection via a syringe. Administration of the drug by syringe has been removed from the package insert.
The KIDs List
The Pediatric Pharmacy Association (PPA) worked with pediatric pharmacists to compile a list of potentially inappropriate drugs for pediatric patients entitled “KIDs List”. The list includes the drugs that should be “avoided” or used “with caution” in all pediatric patients.

Drug Stem Name “-capone”

Medications with the suffix “-capone” denotes a class of drugs known as catechol-O-methyltransferase (COMT) inhibitors. These are used in conjunction with carbidopa/levodopa to treat idiopathic Parkinson’s disease. The following COMT inhibitors are currently approved by the FDA, all in oral tablet form:
  • Entacapone (Comtan)
  • Tolcapone (Tasmar)
  • Carbidopa/Levodopa/Entacapone (Stalevo) combination product containing a ratio of 1:4 carbidopa to levodopa, with 200 mg of entacapone

These drugs inhibit COMT, causing sustained levodopa in the plasma and increased levels of dopamine, decreasing Parkinsonian symptoms. Side effects include postural hypotension, dyskinesias, and central nervous system changes (i.e. hallucinations, compulsive behaviors). A decrease in levodopa doses may be required.

Tolcapone (Tasmar) includes a boxed warning regarding the risk of acute liver failure and is therefore contraindicated in patients with liver disease. Tolcapone should only be used for patients who do not respond to carbidopa/levodopa alone. Discontinue the drug immediately if the patient shows signs of liver impairment (i.e. persistent nausea, fatigue, lethargy, anorexia, jaundice, dark urine, pruritis, and upper quadrant tenderness). Liver studies (SGPT/ALT and SGOT/AST) should be checked at baseline and monitored every 2 to 4 weeks for the first 6 months. Discontinue if improvement is not seen within 3 weeks of initiating therapy.
Stelevo is contraindicated in patients taking nonselective monoamine oxidase inhibitors and in patients with narrow angle glaucoma.

Institute for Safe Medication Practices. (2020). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

Previous issues



June 2020: COVID Related Med Errors December 2019: Confusing Naming Methodologies
May 2020: Leadership During COVID-19 November 2019: Speaking Up
April 2020: Infusion Pumps Outside COVID-19 Patient Rooms October 2019: Literature Review of Independent Double Checks
March 2020: COVID-19 September 2019: Safe Injection Practices
February 2020: Oxytocin Errors August 2019: Methotrexate Mistakes
January 2020: Reporting Errors to ISMP 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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