Healthcare Quality and Safety

The following are samples of medication error case reports submitted through the USP Medication Errors Reporting (MER) Program during the month of November 2003.

Error description: A physician ordered Novolog® Mix 70/30. The order was entered, verified, and administered for one day as Novolin® 70/30. The nurse caught the error on day two. The pharmacist called the physician and suggested to use Humalog® while the patient was in the hospital. The physician insisted that the patient's regimen remain the same as at home. The pharmacist asked the patient to have the medication brought in from home. The medication brought in from home was not Novolog Mix 70/30; rather, it was Novolin® 70/30 InnoLet®. The pharmacist contacted the physician again and had the order changed to Novolin 70/30.
Reporting pharmacist's action/recommendation: The pharmacy computer screen was changed to include a statement following Novolin 70/30 that reads, "NOTE: THIS IS NOT NOVOLOG." A statement following Novolog Mix 70/30 was also included to read, "NOT AVAILABLE."

Error description: A patient was receiving sliding scale insulin. Her blood glucose had been very stable for a few days, so the physician wrote an order to "Decrease Accuchecks to BID. If no Insulin required x 48 h, d/c SSRI." By the context of the order, "SSRI" was intended to mean sliding scale regular insulin. Two days later, the patient had not required any insulin for 48 hours, so the nurse wrote an order as "SSRI to be discontinued (per MD order). Patient has not required insulin over past 48 hours." This order was not sent to the pharmacy, but was communicated to the pharmacist via a note as "d/c SSRI." The pharmacist located the patient's profile, noticed the patient was receiving sertraline (a selective serotonin reuptake inhibitor), and discontinued that. The error was not noticed until two days later, when the nurse noted there was no sertraline in the patient's drawer. One dose was missed and there was no adverse outcome to the patient. The physician was notified of the error and was surprised that the abbreviation "SSRI" caused the sertraline to be stopped.
Reporting pharmacist's action/recommendation: The facility is planning to meet to talk about the Joint Commission on Accreditation of Healthcare Organization's safety standards and how they apply to the use of abbreviated drug names. The facility already has a prohibited list of abbreviations, which does state "do not abbreviate drug names or use acronyms."

Error description: The facility has an automatic dispensing device, which has an automatic order feature. Dextrose 5% in Lactated Ringers was getting low and an automatic order was sent to the wholesaler. The wholesaler sent Sterile Water for Injection. The Sterile Water for Injection was put in the automatic dispensing device's Dextrose 5% in 0.45% Sodium Chloride and 20 mEq Potassium bin. A nurse went to retrieve Dextrose 5% in 0.45% Sodium Chloride and 20 mEq Potassium from the automatic dispensing device, but did not notice the stocking error. Sterile Water for Injection was administered to the patient. The patient experienced mild hemolysis, but there were no long-term sequelae. Prior to this error, the night supervisor asked for a sweep of all Sterile Water for Injection around the hospital. One bag, the one described in this error, was missed because it was sitting on a counter waiting to be hung. The error was discovered by a nurse caring for a different patient. The facility cites inadequate quality control (QC) processes at the supplier's site, and at the facility when restocking the automatic dispensing devices as the cause of this error. In addition, all three products mentioned are manufactured by Baxter and contain the same red labeling, which contributed to the mix up.
Reporting pharmacist's action/recommendation: The facility planned a site visit with the supplier to discuss their QC policies and procedures. The supplier agreed to develop a quality assurance program. The facility reorganized who was actually responsible for stocking the automatic dispensing devices and developed specific restocking procedures. The facility is also planning to implement barcode medication administration.

Potential error: In reviewing the Broselow® Tapes (a medication dosing tool), the facility learned that some of the drugs in their pediatric code carts did not match the concentrations of those on the tapes. A pharmacist discovered this when someone casually mentioned the Broselow Tape dosing tool. The pharmacist asked to see the tape and noticed the problem with the drug concentrations.
Reporting pharmacist's recommendation: The facility has changed the contents of their code carts to match the drug concentrations used on the Broselow Tapes. The reporter also recommends exhorting pharmacists to physically review the entire contents of the code carts and to talk to the appropriate staff to make sure that the medications they use match the dosing tools they're using.

This work was done as part of a grant funded by the Agency for Healthcare Research and Quality for the University of North Carolina for Education and Research on Therapeutics (grant number U18HS010397).

Practitioners are encouraged to submit similar errors to the MER Program. MER is a nationwide program that makes it possible for health professionals who encounter actual or potential medication errors to report to USP confidentially and anonymously, if preferred. By sharing these experiences, pharmacists, nurses, physicians, and other healthcare practitioners contribute to improved patient safety and to the development of valuable educational services for the prevention of future errors. USP reviews each report for health hazards and forwards all information to the U.S. Food and Drug Administration (FDA) and the product manufacturer/labeler. USP will act as your liaison with the FDA and the manufacturer/labeler should you wish to submit a report confidentially.

Practitioners' Reporting News

Cases Submitted to MER