Avoid These Common Medication Mistakes

Staff Training and Education Patient Safety

By: Michael Cohen, RPh, MS, FASHP

Published: 6/14/2021

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The errors that can cause serious patient harm are often preventable.


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.

SPELL IT OUT Error-prone abbreviations should never be used in written documentation and electronic medication orders or administration records.  |  Pamela Bevelhymer

• Medication mix-ups. The mix-ups that occur between tranexamic acid and regional anesthetics such as bupivacaine or ropivacaine highlight the need for more attention and awareness of look-alike and sound-alike (LASA) medications. The errors documented in ISMP’s Medication Errors Reporting Program and from consulting engagements show that when these inadvertent administrations of tranexamic acid occur intrathecally, it has often resulted in serious neurologic outcomes — and even death. As mentioned, mistakes involving these medications are believed to have occurred due to the similarity in vial sizes and identical cap color when selecting vials from “cap up” storage methods.

To avoid this potential for error, organize medication storage areas to avoid the proximity of LASA vials and ampules. Ideally, when setting up storage in anesthesia workstations, automated dispensing cabinets or anesthesia carts, the labels of vials or ampules should be readily visible to the user, not just the caps. Importantly, vials of tranexamic acid should be sequestered and separated from look-alike vials used for regional anesthesia. Consider employing barcode scanning or other machine-readable coding to assist with drug identification prior to preparation and administration.

Errors like these are why ISMP first published its List of Confused Drug Names in 2019 that has hundreds of LASA medication pairings. The list is a useful resource when deciding which safeguards are needed to protect patients from medication-related harm. Effective strategies include using brand and generic names on medication labels; noting the intended purpose of the medication on all prescriptions; constructing computer selection screens in electronic medical records that don’t allow LASA medication names to appear consecutively; and using tall-man and mixed-case letters to alter the appearance of LASA names in order to draw attention to their differences.

• Shorthand shortcuts. Drug abbreviations, symbols and dose designations save time, but they can be misread and misinterpreted. When providers shorten a word or phrase to fit it into a small box on a form, or abbreviate the name of multi-syllabic drugs to avoid misspellings, the shortcut could result in inadvertent patient harm. The biggest errors surrounding shortcuts are associated with doses and measurement units, routes of administration and drug names.

ISMP updated its list of error-prone abbreviations, which have been reported as frequently misinterpreted and involved in harmful errors. Never use them in verbal, electronic or handwritten communications. You can also use our list to update your organization’s “Do Not Use” abbreviation list.

It’s vital to always keep medication safety top of mind and strive to improve how drugs are stored, tracked and administered. Proper medication management, as always, remains an essential component of safe patient care. OSM

 
How Effective Are Your Medication Practices?
SAFETY CHECK
INTERNAL AUDIT ISMP launched a perioperative self-assessment tool, which allows facilities to gauge the effectiveness of their practices and policies.

The Institute for Safe Medication Practices (ISMP) created a self-assessment tool for perioperative settings that will help hospital outpatient departments and freestanding ambulatory surgery centers evaluate the quality of their medication safety practices and identify opportunities for needed improvements. The questions in the survey should heighten awareness of best practices associated with safe medication systems in perioperative and procedural settings, says ISMP Vice President Judy Smetzer, BSN, RN. The assessment should ultimately help facilities realize where gaps exist in their practices compared to national standards.

The self-assessment is divided into 10 sections, including questions focused on drug labeling and packaging, drug storage and distribution, medication delivery devices, staff and patient education, and the communication of drug orders. After the results come in, ISMP plans to review them and create a document of consensus national perioperative best practices for surgery leaders to use, says Ms. Smetzer.

“We think this tool will allow facilities to measure their progress in the medication safety arena over time,” says ISMP president Michael Cohen. “It’s unique in that it will have facility-specific value and help the entire perioperative community as well.”

The nonprofit ISMP received funding from the FDA to create the self-assessments tool and track the results. The deadline to participate is Aug. 31. You can participate anonymously via a secure, password-protected website, and will have unlimited opportunities to view and download your weighted scores during the data-collection period.

— Adam Taylor

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