Abstract
These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs.
Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.
Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at
How Nondrug Allergies are Listed in an Electronic Database
Because electronic health records (EHR) may share a common allergy database between drug prescribing and dispensing systems, it is important to investigate how the EHR identifies and incorporates allergies that are not drug-related.
A patient was seen in a physician practice that uses the same computer system as the hospital, so allergy information entered at the office is available when a patient is admitted to the hospital. During an office visit, a patient reported that she had seasonal allergies. The nurse typed “seasonal” into the allergy database without realizing that the system converted it to the birth control pill Seasonale, (levonorgestrel ethinyl estradiol). When the patient was later admitted to the hospital, the medication reconciliation technician asked the patient about her allergy to the oral contraceptive and learned that the patient did not have a uterus and did not need the contraceptive, but that she did experience seasonal allergies.
In this case with Seasonale, no harm occurred, but imagine a scenario where a patient's oral contraceptive or hormone replacement therapy is never prescribed or is discontinued inappropriately based on incorrect allergy information. We've heard from several other pharmacists about inadvertent Seasonale entries into their computer system's allergy field.
Some computer systems are not designed to accept seasonal allergy, allergy to cat hair, or other nondrug allergies; a drug can only be selected from a drop-down list. The same patient also reported an allergy to cat hair, and the only choice from the drop-down menu was cat hair standard extract. When possible, common allergies should be added to the database, especially if one common EHR is used throughout the system. Some systems allow drug allergies to be separated from all other allergies.
Operating Room Practice: “Stop Using Multiple Dose Vials”
The Association of Periperative Registered Nurses (AORN) released a set of recommended practices for medication safety in the association's 2012 edition of Perioperative Standards and Recommended Practices (http://alturl.com/xapaa). The standards include a recommendation to collaborate with pharmacists to procure and store single dose vials rather than multiple dose vials due to evidence that multiple dose vials pose a risk of cross-contamination as well as overmedication. The organization based its recommendation on documented outbreaks associated with the use of multiple dose vials. The recommendation also notes that, when medications are supplied in quantities that exceed the amount typically given, practitioners may misinterpret the amount in the vial as a single dose, leading to overdoses.
The new AORN standards outline best practices in the operating room (OR) when procuring, prescribing, transcribing, dispensing, administering, and monitoring the effects of medications. Other key recommendations include the following: take a multidisciplinary team approach with pharmacists' involvement in perioperative medication management; develop systems to evaluate compliance with safe practices; assess patients before and after administering medication; and use aseptic technique when transferring medications to the sterile field and during incremental injections.
Last year, the Centers for Disease Control and Prevention (CDC) commented on the use of multiple dose vials, noting that ideally these should be used for a single patient or, if they must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area (http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html). Furthermore, a new Centers for Medicare & Medicaid Services (CMS) surveyor tool has is being field tested during 2012 to evaluate certain infection control processes, including use of multiple dose vials (https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_01.pdf). This is a follow-up to the CDC comment and is in-line with CMS efforts to support recent US government initiatives (eg, Partnership for Patients: Better Care, Lower Costs) to improve patient safety and quality of care in our nation's health care system. The survey item is 2.B.11 and states that “If multi-dose vials are used for more than one patient, they do not enter the immediate patient treatment area (eg, operating room, patient room, anesthesia carts)…. If multi-dose vials are found in the patient care area, they must be dedicated for single patient use and discarded after use.” It is our understanding that The Joint Commission and state health departments surveying nonaccredited hospitals are already citing hospitals for noncompliance.
Etravirine and Ethaverine Mix-Up
ISMP recently received a report about a mix-up between etravirine (Intelence) and ethaverine (Ethatab; Ethavex). Rarely do we receive reports about drug names for 2 different products that are so close to one another in sight and sound.
Etravirine and ethaverine are listed near one another in some computer system databases, and both are available in 100 mg tablets. Etravirine is used in combination with other human immunodeficiency virus (HIV) drugs when patients have become resistant to therapy. It is also available in a 200 mg tablet. Ethaverine, a derivative of papaverine, is used as an antispasmodic in respiratory tract, biliary, gastrointestinal, and genitourinary disorders and to treat vascular disorders. However, it is not listed by the US Food and Drug Administration (FDA) as an approved drug. “Ethaverine” is a recommended International Nonproprietary Name (INN) published by the World Health Organization in 1956. However, the name was never approved by the US naming authority, United States Adopted Names (USAN).
A pharmacist reported that ethaverine was ordered on 2 occasions when etravirine was intended. The errors were made when ethaverine 100 mg was selected using a computerized prescriber order entry (CPOE) system instead of etravirine 100 mg. The name “ethaverine” appeared when the prescriber misspelled the needed drug name using a nonformulary ordering path. The hospital uses Multum for CPOE drug listings. The errors were identified during pharmacist order review.
This sort of error supports the need to include a medication's purpose as part of the order entry process. Also, in this case, the patient had received the correct medication in the past. The physician may not have looked back in the patient's profile to review previous orders; if he did, he likely did not notice that the wrong drug appeared on the current order entry screen. We plan to alert US AN, although it is unclear what action can be taken to alleviate the situation since the drug apparently was never approved here. We will also alert Multum.
Many of the drug name mix-ups reported to the ISMP National Medication Errors Reporting Program involve established (nonproprietary) names. To best protect patients, USAN should work to improve methods used to screen proposed names for medication error potential.
Rapaflo and Rapamune Confusion
A mix-up has been reported between Rapaflo (silodosin), a drug used to treat the symptoms of benign prostatic hypertrophy, and the immunosuppressant Rapamune (sirolimus). The order for Rapaflo was generated from a computer list of the patient's home medications that was collected during the admission assessment. The order was legible and read: “Rapaflo 8 mg daily PO (silodosin capsule).” However, Rapaflo was not among the computer inventory listings or drug dictionary because it was a nonformulary medication. Instead, a pharmacist accidentally selected Rapamune (sirolimus) and scheduled 8 mg to be given PO daily (as 8 × 1 mg capsules, which by itself should have raised concern).
A latent failure associated with the pharmacy computer system was identified as one of the root causes of this error. Within the previous 18 months, a computer upgrade resulted in a “bug,” which discouraged pharmacists from typing more than a few letters of the medication name. If a complete medication name was entered in the computer, some of the medications in the database would not appear on the screen. This reinforced an at-risk behavior of only typing in the first few characters of a drug name, which in this case called up the wrong drug when R-A-P was typed into the system. (This issue was ultimately resolved by the vendor.) A second practitioner reviewing the order did not detect the error, nor was the error captured during the 24-hour chart review by nursing. The patient received 3 doses of the incorrect drug until the error was discovered by a community pharmacist filling discharge prescriptions. There was no known harm to the patient and no decrease in the patient's white blood cell count.
Similar brand and generic names (Rapaflo/Rapamune and silodosin/sirolimus) contributed to this error. Both medications are prescribed in small doses (less than 10 mg). Although the exact dosage strengths do not overlap, the total dose could. In this case, an indication with the order would have helped prevent confusion between these look-alike drug names.