PARENTERAL/ENTERAL THERAPIES
Contribute to this error-reporting project
For more than 10 years, the Institute for Safe Medication Practices (ISMP) and the American Society for Parenteral and Enteral Nutrition (ASPEN) have worked collaboratively to educate clinicians about the benefits of reporting errors involving nutrition support therapy and associated devices. Besides educating the healthcare community about medication errors involving nutrition care, the goals are to learn about underlying causes of these errors, publish and present the findings, develop educational materials and strategies to reduce errors with parenteral and enteral nutrition therapies, and foster national initiatives that address risk reduction for nutrition support.
To report errors involving nutrition support, visit ISMP's error-reporting page (http://www.ismp.org/report-medication-error). For more information about the project, visit the ASPEN-ISMP project site at http://www.ismp.org/ext/645.
UNSCANNABLE BAR CODE
Throwing a curve
Nimbex (cisatracurium besylate) injection is a nondepolarizing skeletal muscle relaxant packaged in a very slim, tall vial. On the label, the bar code is printed horizontally and curves around the circumference of the vial, as shown above. The curvature renders the bar code unscannable with a laser scanner.
Products with a horizontal bar code on a curved surface may not be useable in locations that depend on bar code scanning at the point of drug dispensing and/or administration. The FDA Barcode Rule requires a linear bar code that encodes the product's National Drug Code number. To permit scanning, linear bar codes on round vials should be printed perpendicular to the curve of the vial, usually along the edge of the label on one side, rather than horizontally around the curve of the vial. For safety, facilities that use bar code scanning during product selection should avoid purchasing products with labels that cannot be scanned.
SOUND-ALIKE NAMES
Ure-Na, not hydroxyurea
A one-time dose of hydroxyurea 500 mg was prescribed for a patient with renal failure. Hydroxyurea, an antimetabolite indicated to treat certain cancers, is not normally prescribed as a one-time dose and the patient did not have a condition that was appropriate for the drug. Following up with the prescriber, a pharmacist learned that the intended product was Ure-Na, a palatable form of oral urea available in 15 g pouches. Mixed with water or juice, it is used to treat hyponatremia.
Always check with the prescriber if the indications for a prescribed medication are not consistent with the patient's condition or diagnosis.
SYRINGE SCALES
Fractions lead to confusion
Staff or caregivers could easily be confused when measuring liquid medication doses using the syringe scale printed on Covidien's Monoject 3 mL enteral (ENFit) syringes. As shown in the photo, the scale is marked as 1/2, 1, 1/2, 2, 1/2, 3 mL. If the user misreads the intended 11/2 mL or 21/2 mL as just 1/2 mL, the wrong dose of medication could be prepared and administered to a patient. ISMP has let the company know the syringe scale should be revised because it is not safe to use.
Syringe scales should never indicate doses using fractions. Instead, each point on the scale should indicate the entire volume using numbers and decimals, such as 0.5, 1.5, and 2.5. ISMP recommends that facilities stock an alternate syringe brand with appropriate dosage markings.