CLOSE CALL
Beware of drug names ending in "L"
TraZODone is a selective serotonin reuptake inhibitor indicated to treat major depressive disorder. A prescription for traZODone 50 mg tablets (shown below) was misread as "Trazodone HC 150 Tablet" when the lowercase letter "l" in HCl was placed too close to the strength (50 mg) and was misread as the number 1. A pharmacy technician interpreted this as 150 mg and prepared the label incorrectly. The error was identified by a pharmacist during final verification (there is no traZODone HC), and the error didn't reach the patient.
This close call points out the importance of proper spacing between drug or salt names and doses. For a comprehensive review regarding misidentification of alphanumeric symbols, visit http://www.ismp.org/sc?id=379.
ONE & ONLY CAMPAIGN
Survey reveals alarming safety lapses
To prepare and administer an injectable medication safely, practitioners must follow sterile technique, avoid reuse of single-dose or single-use vials, use needles and syringes just once for only one patient, and never reenter a medication container with a used needle or syringe. However, the results of a CDC survey on injection practices in various settings revealed dangerous knowledge gaps, attitudes, and practices by physicians and nurses alike-despite widespread media coverage of more than 50 outbreaks associated with unsafe injection practices since 2001 and the launch in 2009 of the national One & Only Campaign by the Safe Injection Practices Coalition (http://www.oneandonlycampaign.org). The survey was completed by 370 physicians with a median of 14.5 years of clinical experience, and 320 nurses with a median of 21 years of clinical experience.1
One alarming survey finding was that 12.7% of physicians and 6.7% of nurses mistakenly believe that reusing a syringe to access a medication vial is an acceptable practice. In addition, many respondents reported its actual occurrence in the workplace: 43.2% of physicians and 24.1% of nurses reported reentering multiple-dose vials with a used syringe, and 7.3% and 5.0%, respectively, reported that this usually or always occurs. Belief that this is a safe practice was highest with oncologists and radiologists, and its practice was reported in the workplace by more than half of all anesthesia/pain management physicians, radiologists, and oncologists. More nurses in long-term-care facilities (27.3%) and outpatient facilities (21.8%) reported reentering a vial with a used syringe/needle compared with nurses in acute care facilities (16.1%).
Consistent with other research, this survey reveals that a dangerous minority of healthcare practitioners are violating best practices associated with safe injections and are placing patients at risk for serious infection.2 State licensing boards and professional safety organizations could play a larger role in including injection safety training as a continuing-education requirement. But until that happens, education on safe injection practices should be required during orientation and at ongoing intervals thereafter, and staff competencies should be assessed regularly.3
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