Practitioners' Reporting News

Summary of Recent Cases — Reference Book Error; Broselow® Tape Changes; Vials ≠ Syringes; Dangerous Concentration Expression

Issued August 31, 2004

The following summaries of cases were received through the USP Medication Errors Reporting Program between February – July 2004.

Reference Book Error

Error description: The midnight shift pharmacist received an order for "Pima solution 5 mL po QID (may sub SSKI equiv)." The facility did not stock the Pima® solution. Therefore, the pharmacist needed to prepare the equivalent dose using SSKI®. The pharmacist used the 2004 American Drug Index to look up the concentration of the Pima solution. The American Drug Index listed the Pima solution concentration as "5 gm/5 mL." SSKI, which is available as 1 gram/mL, was entered as an equivalent to Pima, but as 5 gram/5 mL, and 5 mL of SSKI was dispensed. The dayshift pharmacist came on duty, saw the order, and questioned the dose. The dayshift pharmacist discovered that Pima is actually available in a concentration of 325 mg/5 mL, and that the reference book used by the midnight shift pharmacist listed the wrong concentration for Pima. This error caused the patient to receive 5,000 mg because the SSKI concentration is 1 gram/mL (5 mL = 5,000 mg), instead of the intended 325 mg. In addition, this error may have been avoided if the physician had written how many milligrams of Pima solution he wanted instead of writing the number of milliliters intended.

Reporting pharmacist's actions taken/recommendations: American Drug Index was contacted to inform them of the error. According to the reporting practitioner, the error will be corrected in the next edition.

Broselow Tape

Potential error: The facility was performing a mock code. There was confusion over the colors on the Broselow Tape, which did not match the color coded drawers of the Broselow pediatric crash cart. Apparently, the facility purchased new Tapes and the new Tapes have an added color category and different weight ranges. In a high risk situation, this has the potential for increased confusion and error.

Reporting nurse's actions taken/recommendations: After discovering the problem, it was learned that many practitioners in the facility were not aware of the new color category and weight ranges. The facility is reconfiguring their pediatric crash cart to match the new version of the Broselow Tape. The reporting nurse notified the nurse responsible for the inpatient code carts, which also includes this system, and they will all be changed. Additionally, the physician who performs hospital-wide code reviews will alert all personnel via the hospital code team.

To view a similar case regarding Broselow Tape's, click here.

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).

Vials ≠ Syringes

Error description: The facility recently started carrying Aranesp® 60 mcg/1 mL vials. A patient was ordered 40 mcg of Aranesp, so the pharmacist added "40 mcg = 0.667 mL" to the label comment. Sometime after that order was written, someone ordered the 60 mcg syringes, which have a concentration of 60 mcg/0.3 mL (i.e., 40 mcg = 0.2 mL). The pharmacist did not notice that the syringes and vials were different concentrations. Therefore, the concentration was not adjusted on the pharmacy label and the label still read "40 mcg = 0.667 mL," which would equate to 133.5 mcg. Fortunately, the nurse caught this error while verifying the dose prior to administration.

Reporting practitioner's actions taken/recommendations: The staff has since been educated and the facility will now only stock the 60 mcg/0.3 mL syringes. The drugs description in the computer was changed to match the syringe concentration. The reporting practitioner recommends that the manufacturer produce either the vials or syringes only, or make the concentrations the same. Also, pharmacies should be aware of this difference and decide whether to stock the syringes or vials, or both. If both syringes and vials are on hand, mechanisms should be put in place to avoid dosing errors.

Dangerous Concentration Expression

Error description: A young male was brought to the emergency department for treatment of priapism. A urologist was consulted, who ordered epinephrine for penile injection. Confusion resulted from the labeled concentration of 1:1000 on the vial. This concentration was mistaken to mean diluted epinephrine. The patient was administered the concentrated epinephrine (i.e., 1:1000), arrested, and subsequently died.

Reporting practitioner's actions taken/recommendations: The use of 1:1000 to express concentration is a designation from antiquity that only leads to confusion. All manufacturers of epinephrine should remove this concentration expression from their labels immediately.

To view the Institute for Safe Medication Practices recommendations for avoiding errors with epinephrine, click here.


Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.