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Common causes for medication errors identified
Common Causes for Medication Errors Identified Shawn Becker, RN, BSN he United States Pharmacopeia (USP) Medication Errors Reporting (MER) Program provides a forum for health care professionals to report actual or potential medication errors confidentially. The USP MER Program is presented in cooperation with the Institute for Safe Medicine Practices (ISMP). By sharing experiences, nurses, pharmacists, physicians, students, and others in the health professions can work together to improve patient safety. Once the USP receives a report, the information is compiled and analyzed. Reports are forwarded to the Food and Drug Administration (FDA), the product manufacturers (when appropriate), ISMP and the USP Division of Standards and Information Development. In this way, the information can be used to develop or revise product standards, establish appropriate nomenclature, and require packaging and labeling changes. Through this experience, USP has been able to identify common causes for errors, 1 including the use of abbreviations, look-alike or sound-alike names, and similar labeling or packaging.
Table 1. Abbreviations that cause confusion with product names
Abbreviations
D/W PBZ DPT CPZ K-Tab AZT HCT250
MSO4 MTX
Product names
Dextrose in water or distilled water Phenylbutazone or Pyribenzamine Diphtheria, pertussis, tetanus or three different drugs (ie, Demerol, Phenergan, and Thorazine) Chlorpromazine or Compazine Potassium or vitamin K Azathioprine or zidovudine Hydrocortisone 250 mg or hydrochlorothiazide 50 mg Morphine sulfate or magnesium sulfate Mitoxantrone or methotrexate
Approximately 53% of USP MER reports reveal problems and concerns about similar labeling and packaging.
Abbreviations There are more than 10,000 abbreviations used in medicine with more than 16,000 meanings. 2 Approximately 3.5% of USP MER Program reports involve the use of abbreviations that are
Shawn Becker is assistant director of the USP Practitioner and Product Experience Division, US Pharmacopeial Convention, Inc. For reprints write Shawn Becker, RN, BSN, Assistant Director, USP Practitioner and Product Experience Division, US Pharmacopeial Convention, Inc, 12601 Twinbrook Parkway, Rockville, MD 20852. Int J Trauma Nurs 1999;5:113-5.
Copyright © 1999 by the Emergency Nurses Association. 1075-4210/99/$8.00 + 0 JULY-SEPTEMBER 1999
65/1/99723
used with product names, routes of administration, directions for use, and laboratory tests. Although abbreviations may initially appear to save time, they can cause time delays for those who must interpret them. Patients can experience serious problems if the abbreviation results in inadequate care. Table 1 provides examples of commonly used product name abbreviations that have been misinterpreted. Suffixes are often added to trade names to designate a new formulation. Errors can be made if these suffixes are misinterpreted or left off of prescriptions or patients' charts. Table 2 provides examples of drug names with suffixes that have been misinterpreted, and Table 3 lists errors caused by misinterpreting abbreviations used for the route of administration. USP recommends that abbreviaINTERNATIONAL JOURNAL OF TRAUMA NURSING/Becker 113
Table 2. Examples of trade names with confusing suffixes Procardia XL
The XL for extended release was thought to be SL for sublingual.
Catapres-TTS
TTS stands for Transdermal Therapeutic System. It was translated as an order for "two patches applied to the skin" and as "one patch applied on Tuesday, Thursday, and Saturday."
Estratest H.S.
This order was interpreted as "full-strength at bedtime" but it was meant to be "take the medicine at half strength each day."
Megace OS
This improper abbreviation for megestrol oral suspension was interpreted as "instill in the left eye"!
Table 3. Errors caused by using common abbreviations to direct route of administration, the directions for use, or the medication dosage
Abbreviation
Questionable interpretation
SC
"Subcutaneous" or "sublingual" (when handwritten, can be confused with SL)
OD
"Right eye" or "once daily"
Q/D vs QID
The slash can be interpreted as a 1, I, or /
U
As an abbreviation for "units;' it can be misread as a zero. (A patient was ordered to receive "14 units" of insulin but was given a fatal 10-fold overdose of 140 units because the 14U was misinterpreted as 140.)
tions should not be used for chemical names or directions for the route of administration. Health care providers can help by writing legibly and never assuming the interpretation of an abbreviation.
Similar Product Labeling and Packaging Approximately 53% of USP MER reports reveal problems and concerns about similar labeling and packaging. Manufacturers are required by law to place specific information on the label. With injectables, small vials, or ampules it is a challenge to find the appropriate space to print all of the required information. Table 4 provides examples of medication errors caused by misreading similar package labels. The best labels are easy to read and indicate clear differentiations of strength. When this is not available, there is no substitute for reading a label, especially with the proliferation of similar-appearing names and/or packaging. Color coding is usually not the answer to similar packaging because people may be color blind, or when the lighting is poor the colors cannot be differentiated. Questions should be encouraged when using a new drug, and all health care professionals should demonstrate a
114 INTERNATIONALJOURNAL OF TRAUMA NURSING/Becker
thorough understanding of how new products and drug systems should be used before administering medications to a patient. In other situations the labeling may be absent. Medication patches may not have information except on the outer package. Patients should be encouraged to retain the packaging with product information to show health care providers what medication is being used, or for poison control if pets or children handle a used patch.
Preventing Medication Errors Some of the common behaviors that are associated with dispensing the wrong medication include glancing at the label or prescription instead of reading it carefully (at least three times), relying on memory or image to identify medicines, or looking for medicines by color or shape of container. Health care providers can reduce medication errors associated with prescribing, transcribing, dispensing, administering, and monitoring orders if they (1) repeat the drug name and spell it aloud when taking verbal orders, especially on the telephone; (2) use computer entry for medication orders whenever possible; (3) know the intended use of the medication for the patient's diagnosis
VOLUME 5, NUMBER 3
Table 4. Examples of medication errors associated with misreading similar or identical package labels
Medications
Problems
Aminophylline and dextrose 50%
A vial of aminophylline, the bronchodilator, was added by mistake to the parenteral nutrition solution used to treat an infant.
Morphine sulfate and meperidine
Morphine sulfate and meperidine are packaged in identicallooking boxes.
Standard saline intravenous solution and sodium bicarbonate solution (systemic alkalizer; electrolyte replenisher)
Container labels are similar and can be mistaken for one another.
Urokinase 1 mL container contains 5000 units and 1.8 mL container contains 9000 units
The two vials are identical in strength but contain different volumes. The second contains almost an 80% difference.
Ampicillin 500 mg and amoxicillin 500 mg
These products tend to be stored next to each other in the pharmacy and are often confused.
Oxytocin (Pitocin), oxytocic ampules
Small ampules are very hard to read and often contain considerable information.
and include this information in the medication order, on the chart, and in prescriptions; (4) accept only those medication orders that include the product strength and route of administration; (5) insist on clear directions for use, avoiding abbreviations or other shortcuts; (6) communicate with the patient or care giver to intercept medication errors before they occur (eg, patients should be asked what medical problems are being treated and what medicines they are expecting); (7) ask the patient what the provider told him or her to expect while taking the medicine. Medication errors can be prevented and reduced if health care practitioners and patients act responsibly, use proper techniques and procedures, and use safety nets to avoid any and all medication error possibilities. The cause of medication errors can be identified and acted upon to reduce future
JULY-SEPTEMBER 1999
errors when health care practitioners report through a national database and learn from the experiences of others in the health care team.
Acknowledgment USP is pleased to acknowledge Nancy Carothers for her contributions to the draft composition of this article.
REFERENCES 1. United States Pharmacopeia Medication Errors Reporting Program. Understanding and preventing medication errors, an education resource. Rockville (MD): United States Pharmacopeial Convention; 1996. 2. Davis NM. Medical abbreviations: 10,000 conveniences at the expense of communications and safety. Huntington Valley (PA): Neil M Davis Associates; 1993.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Becker 115
Table 1. Abbreviations that cause confusion with product names
Abbreviations
D/W PBZ DPT CPZ K-Tab AZT HCT250
MSO4 MTX
Product names
Dextrose in water or distilled water Phenylbutazone or Pyribenzamine Diphtheria, pertussis, tetanus or three different drugs (ie, Demerol, Phenergan, and Thorazine) Chlorpromazine or Compazine Potassium or vitamin K Azathioprine or zidovudine Hydrocortisone 250 mg or hydrochlorothiazide 50 mg Morphine sulfate or magnesium sulfate Mitoxantrone or methotrexate
Approximately 53% of USP MER reports reveal problems and concerns about similar labeling and packaging.
Abbreviations There are more than 10,000 abbreviations used in medicine with more than 16,000 meanings. 2 Approximately 3.5% of USP MER Program reports involve the use of abbreviations that are
Shawn Becker is assistant director of the USP Practitioner and Product Experience Division, US Pharmacopeial Convention, Inc. For reprints write Shawn Becker, RN, BSN, Assistant Director, USP Practitioner and Product Experience Division, US Pharmacopeial Convention, Inc, 12601 Twinbrook Parkway, Rockville, MD 20852. Int J Trauma Nurs 1999;5:113-5.
Copyright © 1999 by the Emergency Nurses Association. 1075-4210/99/$8.00 + 0 JULY-SEPTEMBER 1999
65/1/99723
used with product names, routes of administration, directions for use, and laboratory tests. Although abbreviations may initially appear to save time, they can cause time delays for those who must interpret them. Patients can experience serious problems if the abbreviation results in inadequate care. Table 1 provides examples of commonly used product name abbreviations that have been misinterpreted. Suffixes are often added to trade names to designate a new formulation. Errors can be made if these suffixes are misinterpreted or left off of prescriptions or patients' charts. Table 2 provides examples of drug names with suffixes that have been misinterpreted, and Table 3 lists errors caused by misinterpreting abbreviations used for the route of administration. USP recommends that abbreviaINTERNATIONAL JOURNAL OF TRAUMA NURSING/Becker 113
Table 2. Examples of trade names with confusing suffixes Procardia XL
The XL for extended release was thought to be SL for sublingual.
Catapres-TTS
TTS stands for Transdermal Therapeutic System. It was translated as an order for "two patches applied to the skin" and as "one patch applied on Tuesday, Thursday, and Saturday."
Estratest H.S.
This order was interpreted as "full-strength at bedtime" but it was meant to be "take the medicine at half strength each day."
Megace OS
This improper abbreviation for megestrol oral suspension was interpreted as "instill in the left eye"!
Table 3. Errors caused by using common abbreviations to direct route of administration, the directions for use, or the medication dosage
Abbreviation
Questionable interpretation
SC
"Subcutaneous" or "sublingual" (when handwritten, can be confused with SL)
OD
"Right eye" or "once daily"
Q/D vs QID
The slash can be interpreted as a 1, I, or /
U
As an abbreviation for "units;' it can be misread as a zero. (A patient was ordered to receive "14 units" of insulin but was given a fatal 10-fold overdose of 140 units because the 14U was misinterpreted as 140.)
tions should not be used for chemical names or directions for the route of administration. Health care providers can help by writing legibly and never assuming the interpretation of an abbreviation.
Similar Product Labeling and Packaging Approximately 53% of USP MER reports reveal problems and concerns about similar labeling and packaging. Manufacturers are required by law to place specific information on the label. With injectables, small vials, or ampules it is a challenge to find the appropriate space to print all of the required information. Table 4 provides examples of medication errors caused by misreading similar package labels. The best labels are easy to read and indicate clear differentiations of strength. When this is not available, there is no substitute for reading a label, especially with the proliferation of similar-appearing names and/or packaging. Color coding is usually not the answer to similar packaging because people may be color blind, or when the lighting is poor the colors cannot be differentiated. Questions should be encouraged when using a new drug, and all health care professionals should demonstrate a
114 INTERNATIONALJOURNAL OF TRAUMA NURSING/Becker
thorough understanding of how new products and drug systems should be used before administering medications to a patient. In other situations the labeling may be absent. Medication patches may not have information except on the outer package. Patients should be encouraged to retain the packaging with product information to show health care providers what medication is being used, or for poison control if pets or children handle a used patch.
Preventing Medication Errors Some of the common behaviors that are associated with dispensing the wrong medication include glancing at the label or prescription instead of reading it carefully (at least three times), relying on memory or image to identify medicines, or looking for medicines by color or shape of container. Health care providers can reduce medication errors associated with prescribing, transcribing, dispensing, administering, and monitoring orders if they (1) repeat the drug name and spell it aloud when taking verbal orders, especially on the telephone; (2) use computer entry for medication orders whenever possible; (3) know the intended use of the medication for the patient's diagnosis
VOLUME 5, NUMBER 3
Table 4. Examples of medication errors associated with misreading similar or identical package labels
Medications
Problems
Aminophylline and dextrose 50%
A vial of aminophylline, the bronchodilator, was added by mistake to the parenteral nutrition solution used to treat an infant.
Morphine sulfate and meperidine
Morphine sulfate and meperidine are packaged in identicallooking boxes.
Standard saline intravenous solution and sodium bicarbonate solution (systemic alkalizer; electrolyte replenisher)
Container labels are similar and can be mistaken for one another.
Urokinase 1 mL container contains 5000 units and 1.8 mL container contains 9000 units
The two vials are identical in strength but contain different volumes. The second contains almost an 80% difference.
Ampicillin 500 mg and amoxicillin 500 mg
These products tend to be stored next to each other in the pharmacy and are often confused.
Oxytocin (Pitocin), oxytocic ampules
Small ampules are very hard to read and often contain considerable information.
and include this information in the medication order, on the chart, and in prescriptions; (4) accept only those medication orders that include the product strength and route of administration; (5) insist on clear directions for use, avoiding abbreviations or other shortcuts; (6) communicate with the patient or care giver to intercept medication errors before they occur (eg, patients should be asked what medical problems are being treated and what medicines they are expecting); (7) ask the patient what the provider told him or her to expect while taking the medicine. Medication errors can be prevented and reduced if health care practitioners and patients act responsibly, use proper techniques and procedures, and use safety nets to avoid any and all medication error possibilities. The cause of medication errors can be identified and acted upon to reduce future
JULY-SEPTEMBER 1999
errors when health care practitioners report through a national database and learn from the experiences of others in the health care team.
Acknowledgment USP is pleased to acknowledge Nancy Carothers for her contributions to the draft composition of this article.
REFERENCES 1. United States Pharmacopeia Medication Errors Reporting Program. Understanding and preventing medication errors, an education resource. Rockville (MD): United States Pharmacopeial Convention; 1996. 2. Davis NM. Medical abbreviations: 10,000 conveniences at the expense of communications and safety. Huntington Valley (PA): Neil M Davis Associates; 1993.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Becker 115