| Topic |
Error |
Best practices and prevention |
| Drug orders |
| Pharmacy computer system |
The system may not detect all unsafe orders. |
Don’t rely on the pharmacy computer system to detect all unsafe orders.
Before giving a drug, understand the correct indication, dosage, route, and potential adverse effects.
Consult the pharmacist if there is any question, and verify the information using an approved current drug reference. |
| Confusing drug names |
Many drugs have names that look alike or sound alike and may easily be mistaken one for the other. |
Perform a medication reconciliation on admission, at each transition of care, and when the practitioner prescribes a new medication. Question any deviations from patient’s routine.
Take your time and read the label carefully.
Consult the ISMP “List of Confused Drug Names.”
Be aware of tall man lettering, which helps differentiate similar drug names. |
| Abbreviations |
Using dangerous abbreviations can result in giving the wrong drug or wrong dose, by the wrong route, or at the wrong time. |
Don’t abbreviate drug names.
Be aware of The Joint Commission’s official “Do Not Use” list of drug abbreviations to avoid
(see Appendix 4: Abbreviations to avoid [The Joint Commission], page 1594).
Consult your facility’s list of approved abbreviations and the ISMP’s “List of Error-Prone Abbreviations, Symbols, and Dose Designations.” |
| Unclear order |
A drug order with incomplete or unclear information can result in giving the wrong drug or wrong dose, by the wrong route, or at the wrong time. |
Ensure that each order specifies the correct drug name, concentration, dosage, route, and frequency of administration.
Clarify all incomplete or unclear orders with the prescriber. Utilize read-back and verify when taking phone and verbal orders. |
| Inadvertent overdose |
A prescriber may write an order for a combination drug such as acetaminophen–opioid analgesic tablets without realizing the total acetaminophen dose could be toxic (don’t exceed 4 g daily). |
Note the amount of acetaminophen in each combined formulation.
Warn patients not to take additional drugs that contain acetaminophen.
Verify any “as needed” pain or fever medication orders to check if they contain acetaminophen. Monitor patient’s use of “as needed” drugs as prescribed. |
| Anticoagulants |
Lack of standardization for drug naming, labeling, and packaging can create confusion. Dosing regimens, assay methods, narrow therapeutic ranges, complex drug interactions, and drug monitoring methods create high potential for complications. |
Keep current with your facility’s anticoagulant therapy protocol, the different dosing regimens, assay methods and their standardized range of normal values, drug interactions, monitoring methods, and reversal regimens for each anticoagulant given.
Don’t confuse direct oral anticoagulants with one another because the drug names are similar, such as confusing rivaroxaban with edoxaban.
Use only unit-dose products if available.
Be especially aware of the correct doses and indications for neonates and children.
Teach patients to manage their therapy appropriately. |
| Drug preparation |
| Crushing drugs for oral or enteral administration |
Crushing certain oral or enteral drugs may:
- alter the drug’s effects, causing overdose or other adverse reactions
- result in skin irritation or other adverse reactions for the preparer
- produce teratogenic effects when administered to patients who are pregnant (through exposure)
- be hazardous if not done in an appropriate environment (e.g., chemotherapy and other hazardous drugs).
|
Use a liquid formulation instead of crushing a drug whenever possible.
Before crushing a drug, always check with the pharmacist and established references, such as the ISMP’s list of “Oral Dosage Forms That Should Not Be Crushed."
|
| Solution color change or particulate matter |
Unusual appearance may indicate that:
- the drug has been improperly stored or manufactured
- the drug has expired
- the wrong drug has been provided by the pharmacy
- the wrong liquid was chosen out of patient’s medication supply.
|
Closely examine all solutions before giving them, and know what their appearance should be.
If you note a color change, contact the pharmacist who dispensed the solution and report it.
Don’t give a drug until verifying that the drug has been correctly labeled and that it is safe to give.
Verify that you have chosen the correct solution from patient’s supply if patient is on more than one liquid drug. |
| Incorrect drug storage |
Incorrect storage may change a drug’s physical properties or result in its being inadvertently administered. |
Follow your facility’s policy for storing drugs.
Always store drugs in the appropriate container, in the appropriate place, at the appropriate temperature, for the appropriate duration. |
| Incomplete or incorrect drug labels |
Incorrect or incomplete labeling can result in giving the wrong drug, formulation, or dose. |
Never give a drug whose label is incomplete or incorrect. Notify the pharmacy immediately and obtain the correctly labeled drug.
Properly label and verify all medications, medication containers, and other solutions on and off the sterile field. |
| Drug administration |
| Using a parenteral syringe for oral or enteral drugs |
Using a parenteral syringe with a luer-lock to prepare small amounts of oral or enteral drugs can result in misadministration because the drug could be accidentally injected into an IV line. |
Always use special oral syringes to give oral or enteral drugs. Their hubs won’t support a needle and they don’t have a luer-lock, so they can’t be attached to IV lines.
Always properly label syringes (if they aren’t thrown away immediately). |
Infusion pump safety
problems |
Problems with infusion pumps (used to deliver controlled fluids, drugs, and nutrients) can cause fluid overload or administration of inaccurate doses. |
Make sure you know how to safely operate an infusion pump. Consult your facility’s policy on proper usage.
Before beginning an infusion, always verify that the pump is working properly. Make sure all alarms are functional and never bypass them.
Double-check all dosing to include the infusion rate.
Always double-check that the correct medication bag is hanging in the pump.
Consult ISMP’s “Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps” for more information. |
| Calculation errors |
Dosage calculation errors can cause significant patient harm, especially with “high alert” medications, and in neonates and children. |
Be aware of medications that are considered high alert. Consult “ISMP List of High-Alert Medications in Acute Care Settings” or “ISMP List of High-Alert Medications in Community/Ambulatory Healthcare."
Write out the mg/kg or mg/m2 dose and the calculated dose as a safeguard.
Whenever a prescriber provides a calculation, double-check it and document that the dose was verified in the medical record.
Use only approved abbreviations, and be aware of the placement of decimal points. |
| OTC products/ supplements (herbal supplements and vitamins) |
Because OTC products, herbal supplements, and vitamins aren’t subject to the same quality assurance standards as drugs, their labels may be misrepresented and their effects and interactions with drugs may not be well studied. |
Always assess and document all OTC drugs, herbal supplements, and vitamins patient is taking in patient’s medical record.
Monitor patient carefully, and report unusual adverse reactions.
Consult an evidence-based drug reference for known drug-herb interactions.
Use extra care when combining herbal supplements with anticoagulants because bleeding times may increase. |