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A pregnant patient died after receiving an inadvertent administration of digoxin instead of bupivacaine during spinal anesthesia. The anesthetist mistakenly removed an ampule of digoxin from an automated dispensing cabinet instead of bupivacaine and administered it intrathecally. The patient experienced severe complications, including dizziness, blurred vision, paralysis, and ultimately brain death. This incident highlights the risk of mix-ups between digoxin and local anesthetics, and recommendations are made to prevent similar errors in the future, such as packaging digoxin in vials and implementing barcode scanning and storage protocols. [Extracted from the article]

January 17, 2022 Pharmacies should address situations in which multiple bottles of tablets are used to refill a cassette. The Institute for Safe Medication Practices (ISMP) recommends reading medication labels 3 times at different points in the product selection and dispensing processes: when obtaining a drug from storage, during use, and when discarding the container or returning it to stock. Completing the entire process of filling a cell before moving to the next and the corresponding drug bottle(s) is critical to ensure that bottles used to refill different cells are not mixed up after barcode verification. [Extracted from the article]

Alternatively, companies can make prefilled syringes available without an affixed needle, so that a safety needle can be placed on the syringe before use. The needles on romosozumab syringes lack a safety device; they are not retractable or even removable, so the nurse was unable to change the needle to one that has a safety guard. [Extracted from the article]

Patients often incorrectly use the product called medicated urethral suppository for erection (MUSE), a urethral alprostadil suppository prescribed for erectile dysfunction. Both patients and pharmacists could easily miss these essential patient instructions, and pharmacists may not give the patient what appears to be a professional package insert. Still, it would be far better if the "patient package insert" was a document separate from the professional package insert and there were enough copies of the patient document to accommodate situations when individual pouches are dispensed. [Extracted from the article]

The prescriber called the original pharmacy to express concern that no one had contacted her regarding the back order and that the pharmacy did not help coordinate a plan of action for the patient to obtain the medication. When a refill was requested, the pharmacy technician working in the specialty pharmacy's call center processed the request and set up a delivery. [Extracted from the article]

Medication Safety INFECTIOUS DISEASE PRESCRIPTION THE INSTITUTE FOR SAFE MEDICATION Practices (ISMP) hasreceived multiple reports about adult patients prescribedand dispensed the pediatric-strength version ofbictegravir/emtricitabine/tenofovir alafenamide(Biktarvy) instead of the adult-strength version,resulting in underdosing. The patient's partner, whowas prescribed Biktarvy from an HIV clinic, told thepatient that the label on the bottle looked different, sothe individual contacted the HIV clinic. [Extracted from the article]

To optimize compliance,education should focus more on cues (eg, flagging that amedication falls under the REMS category in the system)and knowing what resources are available to comply withprogram requirements (eg, REMS policy, REMS resourcebinder). Risk evaluation and mitigation strategy (REMS) programswere first instituted by the FDA in 2007 to ensure thatthe benefits of a medication with serious safety concernsoutweigh the risks.1 Today, there are approximately 60medications that have REMS requirements. Pharmacies should identify whether REMS medications areavailable from their routine distributors andwholesalers, whether the medication is a limiteddistribution drug, or whether there is a need to transferthe prescription to another pharmacy. [Extracted from the article]

Because the generic name of both the timolol once-daily and twice-daily formulations is the same, pharmacies should only carry 1 formulation. During a drug shortage, when another formulation is brought into the hospital, do not allow both formulations to be stocked at the same time. [Extracted from the article]

If a patient's medication list is inaccurate, the patient may receive an incorrect medication or dose, receive a medication too soon or too late if the time of their last dose is inaccurate, receive inappropriate or duplicate therapies, or not receive a critical medication. A fter documenting themedication list in the EHR, ensure the medication and doses are the correct therapy for that patient, given the patient's current state ofhealth, or seek clarification. [Extracted from the article]

Medication Safety Resources for Health Care Professionals IncludeFDA's Patient Eligibility Screening Checklist Toolfor Prescribers IN THE SAFETY BRIEFS BELOW, we look at drug interactions withthe combination of nirmatrelvir and ritonavir (Paxlovid) andwrong route errors with topical drugs. Educate patients, pharmacy staff members, and prescribersabout the potential for Paxlovid drug interactions. [Extracted from the article]

Medication Safety PRESCRIPTION Mark These Products for Mandatory Patient Education onthe Cartons and in the Pharmacy Computer System THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) hasreceived reports about patients swallowing desiccant tabletsthat are packaged within blister cards holding everolimustablets from Biocon Biologics. SAFE PRACTICE RECOMMENDATIONS Because many practitioners will never open theBiocon everolimus carton to see the individualblister cards, it is important to alert them tothe blister-card labeling issue so that they areaware of the potential for patients to ingest thedesiccant tablets. [Extracted from the article]

Death occurs from air embolism after pneumatic line was connected to an intravenous catheter. Therefore, the Emergency Care Research Institute, the FDA, and the ISMP encourage providers to report incidents, even if the misconnection was corrected before reaching the patient. As in the case shared by the FDA, the pneumatic tubing used to inflate the cuff during the procedure had a Luer connector that was compatible with the patient's IV catheter (Figure2). [Extracted from the article]

Learn strategies to safeguard use of the intravenousadministration products to protect patients. In other cases,organizations elect to use alternative products, such asmultichamber bag parenteral nutrition (MCB-PN), for selectpatients instead of patient-specific compounded PN. Use barcode scanningtechnology prior to compounding, dispensing, andadministration to ensure the correct MCB-PN product isbeing used * Convert PN orders. [Extracted from the article]

PATCH COVER APPLIED WITHOUT THE MEDICATION PATCH The ISMP received 5 reports of applying a clon-idine patch adhesive cover directly to the skin without first applying the clonidine patch. To prevent the types of errors described above, consider the following recommendations: Build a medication administration record note to remind LTC nurses to apply the cloni-dine medication patch and not just the cover. Transdermal medication patches submitted to the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) prompted ISMP to look at all patch-related reports it had received within the past 4 years. [Extracted from the article]

A nurse filling in for the patient's primary nurse responded to the pump alarm, turned off the corresponding pump channel, retrieved a new Lactated Ringer's infusion, attached it to the correct pump channel, and programmed the infusion correctly. A discontinued infusion should not be left set up via a stopped infusion pump that either remains connected to the patient and/or hanging on the patient's IV pole at bedside. [Extracted from the article]

The pharmacy's analysis of the event found that the pharmacist conducted the final prescription verification immediately after he completed the order entry and filled the prescription, which limited the effectiveness of the checking process. In a third case, a community pharmacy dispensed Adderall XR 20 mg (dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine sulfate, and amphetamine aspartate monohydrate extended release) to a patient instead of the prescribed Adderall XR 10 mg. [Extracted from the article]

The article offers ideas for pharmacists on preventing vaccine errors. It describes the role of pharmacists as immunization providers, along with a discussion on the risk of error post by the increased availability of immunizations by pharmacists. The different types of errors are explained, such as preparation of reconstitution errors, age group and dosing errors, and wrong patient errors. Ways to prevent errors include labeling vaccine products and using enhanced computer alert system.

Report all vaccine errors internally and to the FDA/CDC Vaccine Adverse Event Reporting System, which is mandatory for COVID-19 vaccine errors under an Emergency Use Authorization.2 The ISMP also asks providers to report vaccine errors to the ISMP National Vaccine Errors Reporting Program.3 7. Ask the parent or patient to provide 2 patient identifiers at the pharmacy counter or when checking in a patient to receive a vaccine: their full name and date of birth. Also, it is unlikely that the vial would accompany prepared syringes, so the vial label cannot be verified by those administering the vaccine or parents or patients receiving the vaccine. [Extracted from the article]

SIRVA is a shoulder injury triggered by the incorrect injection of a vaccine into the shoulder capsule (joint) rather than the deltoid muscle. These do not appear any different than routine shoulder injuries, except that the shoulder symptoms started within days of an IM deltoid vaccination.1 How To Prevent SIRVA The key to avoiding SIRVA is to recognize the anatomical landmarks for identifying the deltoid muscle and to use proper IM administration technique. Shoulder injuries are a real concern because some health care workers may be new to administering vaccines. [Extracted from the article]

However, the high incidence of error reports received by ISMP and others involving 2-component vaccines (eg, vaccine and adjuvant, vaccine liquid and powder components)5 warrants mentioning. LOOK-ALIKE NAMES AND PACKAGING Similar container labels, packaging, and/or vaccine names have contributed to numerous 2020-2021 flu vaccine-related errors. [Extracted from the article]

The article reports on the inclusion of morphine, an opiate, in the list of high-alert medications published by the Institute for Safe Medication Practices (ISMP) in 1989. It states that high-alert medications are drugs that bear a high risk of causing patient harm when used incorrectly. It mentions that several reports have been received by ISMP due to medication errors involving opiates. A chart which offers suggestions for preventing medication errors is also presented.