Hospital Pharmacy

Volume 35, Number 11, pp 1176–1179

2000 Facts and Comparisons

ISMP Medication Error Report Analysis

• Put a Stop to Problem-Prone Automatic Stop

Order Policies
• Pharmacists Should Review All Nonurgent
Drug Orders Before Administration
• Be on Guard for Name Confusion with
Two New Medications

Michael R. Cohen, MS, FASHP*

barbital for epilepsy. Problems result if

These medication errors have occurred in health care facilities at least orders for these drugs are governed by
once. They will happen again—perhaps where you work. Through edu- automatic stop policies and are discon-
cation and alertness of personnel and procedural safeguards, they can tinued by the computer system without
be avoided. You should consider publishing accounts of errors in your warning. Our Canadian affiliate, ISMP-
newsletters and/or presenting them in your inservice training programs. Canada, recently reported such a situa-
Your assistance is required to continue this feature. The reports tion.
described here were received through the USP Medication Errors A hospitalized patient with persis-
Reporting Program, which is presented in cooperation with the Institute tent chest pain was prescribed enoxa-
for Safe Medication Practices. If you have encountered medication parin 100 mg subcutaneously every 12
errors and would like to report them, you may call USP toll-free, 24 hours while awaiting cardiac surgery.
hours a day, at 1-800-233-7767 (1-800-23-ERROR). The hospital had a 7-day automatic stop
Any reports published by ISMP will be anonymous. Comments are order for heparin, including enoxaparin.
also invited; the writer’s names will be published if desired. ISMP may The medication was not reordered prior
be contacted at the address shown below. to the stop date and all the usual “sys-
tem-checks” failed to catch the comput-
er system’s automatic discontinuation of
enoxaparin for this patient. Other fac-
PUT A STOP TO PROBLEM- have implemented electronic systems tors contributing to the error included
PRONE AUTOMATIC STOP with computerized Medication Adminis- the prescriber’s lack of knowledge
ORDER POLICIES tration Records (MARs). For example, about the automatic stop order policy
Automatic stop order policies can automatic stop orders often lack speci- and a weekend stop date. Fortunately,
help safeguard patients against unnec- ficity and fail to consider “exceptions to the error was discovered 24 hours later
essary and prolonged drug therapy. Yet, the rule” for designated drugs and indi- and enoxaparin was immediately
they can also inadvertently add to risk cations. Examples include warfarin for restarted, resulting in no injury to the
for drug-related problems. This has atrial fibrillation, enoxaparin in patients patient.
become more apparent as hospitals awaiting cardiac surgery, and pheno- Years ago, automatic stop orders
played an important role. But today, with
*President, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Hunting-
the patient’s shorter length of hospital-
don Valley, PA 19106. Phone: 215-947-7797. Fax: 215-914-1492 E-mail: mcohen@[Link]. ization and the expanding role of clinical
Web site: www. [Link] pharmacists, this tool from the past

1176 Volume 35, November 2000

ISMP Medication Error Report Analysis

most probably needs adjustment. After then discontinued medications below) verification before drug administration,
reviewing applicable state regulations, and place it in the medical record with users may allow varying capabilities to
evaluate the list of drugs currently gov- the most recent progress notes. As pre- “override” this feature.
erned by automatic stop policies to scribers and nurses review it, unintend- If there is an urgent clinical need for
determine if there is a valid need to con- ed discontinuation or continuation of administering a drug before a pharma-
tinue enforcing the policy. It’s likely that drugs may be promptly recognized and cist can reasonably be expected to
you will be able to reduce the list con- corrected. Patients should also be review the order and dispense the drug,
siderably. encouraged to ask questions when a it is important to have readily accessible
One hospital concluded that only medication is suddenly stopped. medications. Yet, a clear process is
four drugs required an automatic stop needed to determine when such an
policy: Toradol (ketorolac), 5 days to PHARMACISTS SHOULD urgent situation exists, and safeguards
prevent gastrointestinal bleeding); REVIEW ALL NONURGENT must be established for the storage,
Demerol (meperidine), 4 days to pre- DRUG ORDERS BEFORE removal, and administration of drugs
vent accumulation of normeperidine; ADMINISTRATION available in automated and nonauto-
paralytic agents, 48 hours to prevent Administering a drug before a phar- mated floor stock.
adverse effects on nerve conduction macist has reviewed the order and Carefully select floor stock and pro-
that may cause prolonged paralysis or screened it for safety increases the risk vide drugs in limited quantities, single
problems weaning patients off ventila- of a medication error, most notably for concentrations, and in unit doses. If
tors; and antibiotics, 7 days—a realistic allergenic drugs, drugs at unsafe doses, automated dispensing cabinets are
timeframe considering the average or drugs with unrecognized food or drug linked to the pharmacy computer sys-
length of stay. interactions. If patient harm could result tem, establish a restricted list of urgent
Another option may be to identify from delayed therapy, the benefit of or emergent drugs that may be avail-
exceptions (such as the ones listed administering a drug in an emergency able via the “override” feature. As need-
above), exclude them from the policy, or urgent situation may outweigh the ed, apply warnings (allergy alert, etc.) to
and encourage prescribers to include safety of prospective pharmacy review the packages of “override” drugs to
the drug’s indication and duration for of the order. But it is unsafe to routinely enhance safety. Even if an ordered drug
medications governed by automatic bypass such a crucial step for conve- is on an “override” list, nurses should
stop orders to prevent unintended dis- nience or to remedy process problems ask, “Does the clinical need for quick
continuation. Computerized systems such as excessive order turn-around administration outweigh the safety of
make policy exceptions a realistic time. For example, whether medications having a pharmacist review the order
option. When possible, incorporate the are obtained from floor stock or auto- first?”
duration of drug therapy in diagnosis- mated dispensing cabinets, it’s risky to For example, Pepcid (famotidine)
specific protocols/standardized orders. remove and administer noncritical first may be on an “override” list and its
Clinical pharmacists should review doses and other routine medications quick administration before pharmacy
drug therapy daily and take a leading that can safely wait until a pharmacist is review may be warranted for a patient in
role in contacting prescribers when nec- able to review the order. serious gastric distress. The order
essary to confirm continuation or dis- Such a practice is also likely to should be reviewed before subsequent
continuation of an order. Consider pro- result in a Joint Commission Type I rec- doses are administered (or immediately
viding clinical pharmacists with hospital- ommendation. Standard TX.3.5.2 after the pharmacy reopens). However,
endorsed authority to extend or remove requires that a pharmacist review all pharmacy review may be accomplished
automatic stop dates for specified drugs medication orders before administration without compromising care for the first
and indications. Configure computer except in emergency situations when Pepcid dose for a newly admitted, com-
systems (and MARs) so that drugs are time does not permit review, or where a fortable patient who’s been taking the
not automatically discontinued without licensed independent practitioner con- drug at home.
notice. trols ordering, dispensing, and adminis- Before administration, drugs
It is equally important to examine tration (eg, in the emergency depart- obtained through the “override” feature
the systems in place for notifying pre- ment or during surgery). should be independently double-
scribers about automatic stop orders, Ensuring prospective pharmacy checked by a second practitioner. Time-
the timing of the notification, and the order verification is difficult when drugs ly order verification and minimal turn-
process for review. Print a daily drug are readily available in patient care around time is also important to avoid
summary from the pharmacy computer units. Even if automated dispensing unnecessary use of floor stock. Decen-
system (listing current drug therapy first, cabinets offer the capacity for pharmacy tralized pharmacists can speed these

1178 Volume 35, November 2000

 ISMP Medication Error Report Analysis

strengths makes it even easier to misin-

terpret the drug’s name. Carba-
mazepine is available in 100, 200, and
400 mg (extended-release) oral tablets,
and Tequin is also available in 200 mg
or 400 mg oral tablet strengths. Famil-
iarity and association with the word
FIGURE 1. Avandia prescription
“equine” seems to invite mispronuncia-
tion and misspelling of Tequin with an
added “E” at the end of the name (which
when scripted can look like the “L” in
Tegretol). Likewise, unfamiliarity with
newer drugs on the market, such as
Tequin, invites misinterpretation with
other look-alike drug names with which
staff are more familiar.
As with the Avandia–Coumadin
pair, health professionals should inde-
FIGURE 2. Tequin prescription
pendently confirm the patient’s diagnosis
before dispensing. Use reminders on
drug containers and build alerts for com-
processes. of a mix-up. Figure 1 is an actual pre- puter systems. Also, an effective formu-
Monitor “override” drugs regularly scription order for Avandia that was lary addition process, which includes
and consider determining a monthly sent to us recently. It was initially mis- analysis of “error potential” and staff edu-
“override” rate (number of drugs given read as Coumadin. cation, can help prevent staff from mis-
before pharmacy review/total number of Fortunately, the pharmacist in this taking orders for newer drugs with older,
drugs administered). Reduce the rate case did recognize that the prescription more familiar drugs.
over time. could be interpreted either way, and
If using floor stock or automated clarified with the prescriber that Avandia
dispensing cabinets without a pharma- was intended. Since accidental admin-
cy interface, nurses should follow the istration of either drug would pose a
same process to carefully determine if a great danger to any patient, we thought
drug should be given before pharmacy it would be worthwhile to remind physi-
review. Since nurses have no way to cians, nurses, and pharmacists about
determine if pharmacy has reviewed an the potential for errors. To reduce the
order, at best, they could wait a set peri- chance of error, prescriptions for either
od of time to allow for pharmacy review drug should always include the medica-
before retrieving the drug from floor tion’s purpose. Also, nurses and phar-
stock. Again, decentralized pharmacists macists must clarify the purpose of
could improve communication. either drug prior to dispensing and
administration.
BE ON GUARD FOR NAME We’ve also received a report about
CONFUSION WITH TWO NEW confusion between Tegretol (carba-
MEDICATIONS mazepine) and Tequin (gatifloxacin).
Poorly written orders for the antidi- The order shown in Figure 2 was read
abetic medication Avandia (rosiglita- by a pharmacist as Tegretol, but it’s
zone) can look like Coumadin (war- actually an order for the antibiotic
farin). Both are available as 4 mg oral Tequin.
tablets, which increases the likelihood Similarity in the available tablet

Hospital Pharmacy 1179