ISMP
MEDICATION ERRORS ANN SHASTAY, MSN, RN, AOCN
Caution: Drug Names That End With the Letter “L” A nurse transcribed an order for lisinopril 2.5 mg by mouth (PO) daily for a patient who was transitioning from the emergency department (ED) to an inpatient area by copying the prescriber’s orders that were previously on hold. However, the nurse read the dose as 12.5 mg PO daily (Figure 1), seeing the final “L” in lisinopril as the number one (1). Usually, the attending physicians who admit patients from the ED at this hospital ask the nurses for an assessment of the
Figure 1. Final “l” in lisinopril was seen as the numeral 1, making the dose “12.5 mg” instead of 2.5 mg.
patient’s condition, medications, diagnostic tests, and other clinical features. They then generally order the continuation of the medications, which have been written pending the patient’s admission. In reality, nurses rarely read back all of these medication orders, which is probably why the mistake was not recognized. The patient received several incorrect doses and eventually developed hypotension, which required special monitoring. Drug names that end with the letter “L” have occasionally been the subject of overdoses reported to the Institute for Safe Medicine Practices (ISMP). ISMP’s list, Error-Prone Abbreviations, Symbols, and Dose Designations (http:// www.ismp.org/Tools/errorpro-
vol. 32 • no. 9 • October 2014
neabbreviations.pdf) mentions this problem, and we also wrote an article (http://www.ismp.org/ Newsletters/nursing/Issues/Nurse AdviseERR201006.pdf) on misidentification of alphanumeric symbols in handwritten and computer-generated information. Advise prescribers to leave sufficient space between the numeric dose and the drug name, and to ensure that the last letter of the drug name is not separated from the rest of the drug name with a space (as seen in Figure 1). This also applies to electronic prescribing and standard order sets because errors can occur if sufficient space is not provided between the drug name and strength (e.g., lisinopril 2.5 mg). If verbal orders are taken, be sure to read back the order and spell out the drug name.
Medical Equipment, Not a Toy A school-age child was given a syringe for play. She used the syringe to drink water and eat ice cream. The next morning the child complained of chest pain and a cough so her family called 911 right away. The child said that she had connected the syringe to her central intravenous (IV) line and had pushed in air. Appropriate rescue measures were initiated and, fortunately, the child recovered without further incident. Never allow children to play with IV syringes.
ON-Q Pump Has Luer Connector Tubing associated with the ON-Q PainBuster Post-Op Pain Relief System (I-Flow Corporation, Irvine, CA) can be inadvertently attached to an IV line or
other infusion equipment with a Luer connector. The pump (Figure 2) is intended to provide continuous delivery of a local anesthetic, such as bupivacaine, to surgical wound sites. With bupivacaine and other local anesthetics delivered via the device, inadvertent attachment to an IV line can lead to cardiac
Figure 2. ON-Q PainBuster device should not be connected to intravenous tubing as shown.
toxicity and death. While demonstrating the device to a group of nurses, a pharmacist accidentally connected the Luer connector on the ON-Q pump with IV tubing, thus identifying the risk of misconnection. A “catheter site—no IV access” label is included with the packaging, but it may not be used by staff. Further, including the terminology “… IV access” on the label could result in a practitioner not seeing the “No” part of the warning, thus believing it is intended for IV use. A better option would be to affix a label stating, “Warning: regional block only.” No actual error has been reported to ISMP. The company has been notified of this design issue. Ann Shastay, MSN, RN, AOCN, is the Managing Editor, Institute for Safe Medication Practices, Horsham, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices, 200 Lakeside Dr., Suite 200, Horsham, PA 19044 (ashastay@ ismp.org). DOI:10.1097/NHH.0000000000000141
Home Healthcare Nurse 557
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
MEDICATION ERRORS ANN SHASTAY, MSN, RN, AOCN
Caution: Drug Names That End With the Letter “L” A nurse transcribed an order for lisinopril 2.5 mg by mouth (PO) daily for a patient who was transitioning from the emergency department (ED) to an inpatient area by copying the prescriber’s orders that were previously on hold. However, the nurse read the dose as 12.5 mg PO daily (Figure 1), seeing the final “L” in lisinopril as the number one (1). Usually, the attending physicians who admit patients from the ED at this hospital ask the nurses for an assessment of the
Figure 1. Final “l” in lisinopril was seen as the numeral 1, making the dose “12.5 mg” instead of 2.5 mg.
patient’s condition, medications, diagnostic tests, and other clinical features. They then generally order the continuation of the medications, which have been written pending the patient’s admission. In reality, nurses rarely read back all of these medication orders, which is probably why the mistake was not recognized. The patient received several incorrect doses and eventually developed hypotension, which required special monitoring. Drug names that end with the letter “L” have occasionally been the subject of overdoses reported to the Institute for Safe Medicine Practices (ISMP). ISMP’s list, Error-Prone Abbreviations, Symbols, and Dose Designations (http:// www.ismp.org/Tools/errorpro-
vol. 32 • no. 9 • October 2014
neabbreviations.pdf) mentions this problem, and we also wrote an article (http://www.ismp.org/ Newsletters/nursing/Issues/Nurse AdviseERR201006.pdf) on misidentification of alphanumeric symbols in handwritten and computer-generated information. Advise prescribers to leave sufficient space between the numeric dose and the drug name, and to ensure that the last letter of the drug name is not separated from the rest of the drug name with a space (as seen in Figure 1). This also applies to electronic prescribing and standard order sets because errors can occur if sufficient space is not provided between the drug name and strength (e.g., lisinopril 2.5 mg). If verbal orders are taken, be sure to read back the order and spell out the drug name.
Medical Equipment, Not a Toy A school-age child was given a syringe for play. She used the syringe to drink water and eat ice cream. The next morning the child complained of chest pain and a cough so her family called 911 right away. The child said that she had connected the syringe to her central intravenous (IV) line and had pushed in air. Appropriate rescue measures were initiated and, fortunately, the child recovered without further incident. Never allow children to play with IV syringes.
ON-Q Pump Has Luer Connector Tubing associated with the ON-Q PainBuster Post-Op Pain Relief System (I-Flow Corporation, Irvine, CA) can be inadvertently attached to an IV line or
other infusion equipment with a Luer connector. The pump (Figure 2) is intended to provide continuous delivery of a local anesthetic, such as bupivacaine, to surgical wound sites. With bupivacaine and other local anesthetics delivered via the device, inadvertent attachment to an IV line can lead to cardiac
Figure 2. ON-Q PainBuster device should not be connected to intravenous tubing as shown.
toxicity and death. While demonstrating the device to a group of nurses, a pharmacist accidentally connected the Luer connector on the ON-Q pump with IV tubing, thus identifying the risk of misconnection. A “catheter site—no IV access” label is included with the packaging, but it may not be used by staff. Further, including the terminology “… IV access” on the label could result in a practitioner not seeing the “No” part of the warning, thus believing it is intended for IV use. A better option would be to affix a label stating, “Warning: regional block only.” No actual error has been reported to ISMP. The company has been notified of this design issue. Ann Shastay, MSN, RN, AOCN, is the Managing Editor, Institute for Safe Medication Practices, Horsham, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices, 200 Lakeside Dr., Suite 200, Horsham, PA 19044 (ashastay@ ismp.org). DOI:10.1097/NHH.0000000000000141
Home Healthcare Nurse 557
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
