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Avoid These Common Medication Mistakes
The errors that can cause serious patient harm are often preventable.
Michael Cohen, RPh, MS, FASHP
Publish Date: June 14, 2021   |  Tags:   Patient Safety Staff Training and Education
Limited Withdrawls
LIMITED WITHDRAWALS Automated dispensing machines help with medication safety, but to really limit opioid use, facilities should limit the amounts of overrides allowed on the devices, and require written orders for their approval.   |   Pamela Bevelhymer

The medication errors that cause serious patient harm can be avoided through better safety practices and system changes. Half of the items that landed on the Institute for Safe Medication Practices’ list of the 10 most frequently reported mistakes in 2020 put patients at risk in outpatient perioperative settings. Here’s what they are and our recommendations on how to address them.

Inappropriate opioid prescribing. Despite the ongoing national opioid crisis, ISMP continues to receive reports of opioid-naïve patients receiving extended-release opioids, which are typically prescribed to manage chronic pain and can result in serious harm in patients who are not taking opioids on a routine basis. Much of the attention is on making practice changes in emergency rooms, but outpatient surgical departments should take heed as well.

Ensure your care team has access to patients’ medication records in order to document their history of opioid use. Next, establish definitions for a patient’s opioid status, including “opioid naïve” for patients who don’t take the painkillers every day or are unfamiliar with the drug’s potential dangers, and “opioid tolerant” for patients who take opioids daily or have a history of daily opioid intake. Develop and implement a system to gather and document each patient’s opioid status and note the pain types with which they present.

Cases have been reported to ISMP that older, opioid-naïve patients were prescribed extended-release opioids because they said they were “allergic” to short-acting codeine, when it fact their reactions were due to minor drug intolerances. So, when collecting allergy information from patients, be sure to make the distinction between true drug allergies and what might be minor intolerances. When prescribing, dispensing or administering opioids, always strive for the lowest dosages and frequencies. And, of course, embrace multi-modal anesthesia that is as opioid-sparing as possible as often as appropriate.

Misuse of infusion pumps. Our organization recommends using smart infusion pumps with dose-error reduction systems (DERS), which alert providers of incorrect medication orders or calculation errors that could result in the wrong amount of drug or fluid being administered on all smart infusion pumps. But use of DERS in perioperative settings is limited. Some anesthesia providers simply don’t understand the loading/bolus capabilities of smart pumps, but the main reason for their limited use is a lack of requirement to do so. ISMP therefore urges facilities to set clear expectations that they must be used for all infusions. Some anesthesia providers don’t like the soft- and hard-dose infusion limits set in the pumps because they were not included in establishing the limits for anesthesia/perioperative medications. To remove this barrier, involve the anesthesia providers when building the smart pump drug library. 

Many ORs operate smart pumps on “anesthesia mode,” failing to understand that this default setting on some pumps reduces hard stops to soft ones, which can result in dangerous overrides of dosing and concentration limits that should never be bypassed. A range of hard limits for medication doses should be implemented and putting the pumps on “anesthesia mode” shouldn’t be allowed if it restricts the ability to individualize a patient’s infusion limit. Anesthesia providers should be required to use a bolus setting with hard limits for catastrophic doses whenever the feature is available.

Wrong-route tranexamic acid injections. This potentially fatal error is the only item on last year’s list of top medication errors that also appeared on the 2019 list. The majority of the accidents happen when staff confuses tranexamic acid, which is supposed to be used to control bleeding during surgeries, with local anesthetics bupivacaine and ropivacaine because all three medications can come packaged with caps that are the same shade of blue.

The ongoing occurrences led to a 2020 National Alert Network warning, and the FDA in December revised tranexamic acid labeling to highlight that it’s supposed to be administered intravenously and strengthened the wording of the prescription information to include stronger warnings about the risk of wrong-route errors.

ISMP strongly urges several additional precautions: Store tranexamic acid in a different location than lookalike vials and add a label that highlights it’s intended for IV-only administration and purchase connectors for local anesthetics that are designed to prevent misconnections with drugs intended for IV use.

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