Need for standardizing critical care druginfusions has never been greaterPROBLEM: Several errors occurred with a norepinephrine infusion that was administeredto a coronavirus disease 2019 (COVID-19) patient via a smart infusion pump positionedoutside the patient’s room. The smart pump was set up with a standard administrationset plus three attached extension sets, with tubing running from the pump, under thedoor, and to the patient. A pharmacist responded to the patient’s intubation and assistedwith preparing medications from outside the patient’s room. The patient was hypo-tensive, so the pharmacist prepared a standard norepinephrine infusion containing4 mg/250 mL (16 mcg/mL) and applied a handwritten label to the bag.

The first two mistakes occurred when programming the initial norepinephrine infusion.The smart infusion pump asked the nurse to indicate whether the norepinephrinedosing was weight-based or not since both mcg/kg/minute and mcg/minute dosingwere available for the medication. The nurse chose the weight-based dosing optionand, thus, programmed the pump to deliver the infusion as mcg/kg/minute insteadof the verbally prescribed infusion rate of mcg/minute. The nurse also mistakenlyselected the maximum concentration in the library of 32 mg/250 mL (128 mcg/mL)instead of the prepared concentration of 4 mg/250 mL (16 mcg/mL). However,since the vasopressor was being titrated toeffect for hypotension, neither programmingerror adversely affected the patient.

Soon afterwards, the patient’s physicianentered the order for the norepinephrineinfusion, selecting the more concentratednorepinephrine infusion (32 mg/250 mL) due to significant fluid restrictions in place forthe patient. The pump was already erroneously programmed for that concentration, sothe nurse continued it. Barcode scanning could not be used for the medication becausethe bag infusing had a handwritten label without a barcode. The pharmacy prepared anew bag containing 32 mg/250 mL, which was not hung at this time.

The error was caught when the nurse for the next shift inspected the original infusionbag while switching to interoperability (bidirectional communication of data betweenthe electronic health record [EHR] and the infusion pump). The nurse consulted apharmacist to see what the dose was in mcg/min, hung the new bag, corrected thepump, and changed the tubing.

Over the course of the patient’s stay, the patient was switched between the standardand more concentrated norepinephrine infusions several times. Multiple tubing changesoccurred during the changes in concentrations, worsening the shortage of extensionsets. The nurses  suspected that they might have inadvertently administered somebolus doses to the patient, who experienced unexpected blood pressure changes. Also,with the low rate of infusion for the concentrated norepinephrine, nurses were notconfident that the medication was reaching the patient given the volume left in theextension sets.   

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FentaNYL patch duration of drugdelivery confused as patch strength.Transdermal fentaNYL 75 mcg per hourpatches were dispensed for a patient withdirections to apply one patch every48 hours. However, the physician hadprescribed fentaNYL patches 50 mcg perhour. The hard copy of the prescriptionread, “fentaNYLpatch 72 hour 50 mcg/hourtransdermal, one patch to the skin every48 hours.” The pharmacy staff who enteredthe prescription into the pharmacy com-puter system read “fentaNYL patch 72,”which led him to mistakenly select a 75 mcgper hour patch instead of a 50 mcg perhour patch. The inclusion of the durationof controlled drug delivery (i.e., 72 hours)in the drug description field contributed tothis dispensing error.

To reduce the risk of this type of confusion,the duration of controlled drug delivery(i.e., 72 hours) should not be listed withinthe product description, which shouldinclude the release rate per hour (in thiscase, 50 mcg/hour). The dosing instruc-tions should communicate the frequencyof changing the patch (in this case, every48 hours).

Transdermal fentaNYLpatches deliver thelabeled amount of drug for 72 hours evenif they are ordered to be changed morefrequently (i.e., every 48 hours). Officialprescribing information mentions that asmall proportion of adult patients may notachieve adequate analgesia using a 72-hour dosing interval and may requirechanging the patch every 48 hours ifadequate pain control cannot be achievedusing a 72-hour regimen. According to theprescribing information, an increase in thedose should be evaluated before changingthe dosing interval in order to maintainpatients on a 72-hour regimen.

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Supported by educational grants from Novartis and Fresenius Kabi

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Nurses suspected theymight have inadvertentlyadministered bolus doses

to the patient...

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SAFE PRACTICE RECOMMENDATIONS: The pharmacist who reported this eventstated that programming errors with norepinephrine have happened previously(before the COVID-19 pandemic) since both mcg/kg/minute and mcg/minute areoptions for prescribing, as well as choices in the facility’s pump library. The organ-ization is exploring standardizing to either weight-based (mcg/kg/minute) or non-weight-based (mcg/minute) dosing for norepinephrine to reduce the opportunitiesfor error. The American Society of Health-System Pharmacists (ASHP) Standardize 4Safety initiative recommends using mcg/kg/minute dosing units for norepinephrine(www.ismp.org/ext/446).

Also, instead of using new extension sets with each change in concentration, a betteroption during a shortage might have been to disconnect the existing extensiontubing from the patient, flush it with the new concentration, and reattach it to thepatient. However, the trade-off is an increased risk of infection with each disconnectionand reconnection; thus, aseptic technique is paramount.

Easy for things to go wrong with test patientsPROBLEM: A health system shared its electronic health record (EHR) services andused the same information technology vendor among its various hospitals. A statesurveyor at one of the hospitals (hospital A) asked an emergency department (ED)nurse to look at its “door-to-needle” process for getting alteplase injection to strokepatients. In demonstrating the system, the nurse found a test patient with a fictitiousname in the EHR, “admitted” her, and then entered an order for alteplaseinjection. After describing the rest of the process, the surveyor was satisfied.

The nurse at hospital A had actually “admitted” the test patient with a fictitiousname to another hospital in the system (hospital B). As a result, the test order foralteplase was transmitted to the pharmacy at hospital B. Because there was anactual stroke patient in the ED at hospital B, the pharmacist had been expecting anorder for alteplase, but she never noticed the test patient’s name associated withthe order.

Fortunately, the pharmacist did notice the odd dose of alteplase that the nurse athospital A had entered. The odd dose led the pharmacist to call the ED nurse caringfor the known stroke patient at hospital B, who assessed the patient’s weight anddiscovered the error. The nurse then entered the weight-based dose of alteplase inthe EHR for the actual ED patient at hospital B, mistakenly believing the ED physician(rather than the nurse at hospital A) had simply entered the alteplase order at thewrong dose into the patient’s EHR. The trouble is, the ED physician at hospital B didnot want this patient to receive alteplase at all. Luckily, the ED physician interceptedthe error before it reached the patient. 

SAFE PRACTICE RECOMMENDATIONS: Do not create test patients in a live EHR envi-ronment. Instead, use a test environment whenever possible. In this health system,the hospital had created a separate test environment with test patient profiles forsuch purposes, but not all staff were aware; this should be a topic during practitionerorientation to the EHR system. Additionally, a test patient with a fictitious name wasavailable in the live EHR system. As we have mentioned in the past, with testing ina live EHR, even if you think you will remember to correct any erroneous entriesmade during testing, interruptions or distractions could lead to a catastrophic error.Unfortunately, some EHR vendors have not created special test systems. But hospitalsshould stand firm in denying requests to operate a test scenario within a live system.If, for some reason, you must enter a test patient within a live system, the patient’sname should make it obvious that it is not a real patient (e.g., call them “Test Patient”).

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© 2020 ISMP. Reproduction of the newsletter or its content for use outside your facility, including republication of articles/excerpts or posting on a public-access website, is prohibited without written permission from ISMP.

Mix-up between droperidol anddronabinol. A pharmacist received a callfrom a physician assistant (PA) requestinghelp with ordering a medication for apatient with nausea and vomiting. The PAtold the pharmacist he was looking fordronabinol in the electronic health record(EHR) drug dictionary but could not find it.The pharmacist clarified the brand name(MARINOL) and the generic name (dron-abinol) as well as the indication (nauseaand vomiting). The pharmacist then askedwhat dose was needed, to which the PAreplied, “5 mg.” It was not discovered untillater that the PA had actually been look-ing for droperidol (formerly available asINAPSINE), not dronabinol, to treat thispatient’s nausea and vomiting.

Dronabinol is a synthetic oral cannabinoidsometimes used as an antiemetic duringchemotherapy and is also used to treatloss of appetite and weight loss. It is avail-able in capsules (2.5, 5, and 10 mgstrengths) and an oral solution (5 mg/mL,brand name SYNDROS). Droperidol is anantipsychotic that plays a role in reducingnausea and vomiting by blockingdopamine stimulation in the chemorecep-tor trigger zone. It is available as a solutionfor injection (2.5 mg/mL). Hearing the PArequest a dose of “5 mg,” a reasonablestarting dose for either medication, likelyplayed a role in confirmation bias, mak-ing both the PA and pharmacist believethey were talking about the correct drug.Unfortunately, neither the pharmacist northe PA clarified the route of administrationfor the medication being ordered, nor didthe PA recognize the discrepancy whenthe pharmacist mentioned the brandname, Marinol.

During verbal communication of medica-tion orders, it is imperative for the pre-scriber to speak clearly and the receiverto always follow through with readbackto ensure there is no miscommunication.Spell out sound-alike drug names whenreading back a verbal order. Specify allportions of the medication order whenprescribing and during readback (e.g.,patient’s name and identifiers, drug name,strength, dose, dosage form, indication,frequency, route, provider). If either party

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Furthermore, in the event described above, the test patient available in the live EHRsystem at hospital A was able to be “admitted” to hospital B. While hospital A and Bwere within the same health system and used the same EHR system, one hospitalwithin the system should not be able to impact the workflow at another hospitalwithin the system by “admitting” patients to the other location.

Additionally, this event should lead to further analysis of the communication betweenthe nurse and pharmacist at hospital B when discussing the real patient’s weight.One wonders if the patient’s name was mentioned at all. A standard communicationprocess that includes the patient’s full name should be established and used when-ever discussing patient care.

Finally, provide staff with clear instructions and procedures to follow when asked todemonstrate workflow to surveyors. We hope that surveyors would avoid askingand expecting practitioners to create a workflow in a live EHR system using testpatients, and they should not be asking for an order to be entered and retracted ona real patient. In this case, the “door-to-needle” workflow could have been explainedwithout entering an alteplase order on a test patient.

The “-xaban” drug stem name

Medications with the suffix “-xaban” belong to a class of anticoagulants known asfactor Xa inhibitors,1 commonly referred to as “factor 10 inhibitors.” Anticoagulantsincrease the time it takes for blood to clot. Oral medications in this class are oftenreferred to as direct oral anticoagulants (DOACs). There is another DOAC, PRADAXA(dabigatran) that is not a factor Xa inhibitor; instead, it is a direct thrombin (factor IIa)inhibitor and will not be discussed in this article.

The stem “-xaban” provides helpful clues in remembering how medications in thisclass work. The first part of the stem, “xa,” identifies where the drug acts—on coag-ulation factor Xa. The second part of the stem, “ban,” refers to the fact that the drug“prohibits” further clotting activation by binding to factor Xa, which prevents the con-version of prothrombin to thrombin, inhibiting the production of fibrin and the initiationof blood clot formation.

There are currently three oral and one injectable factor Xa inhibitors available in the US(Table 1, page 4). These drugs are typically prescribed for the treatment and preventionof deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as the preventionof stroke and systemic embolism in patients with non-valvular atrial fibrillation.

Dosing varies based on the indication. When treating a DVT or PE, both apixaban andrivaroxaban have higher starting doses, which are then lowered after 7 or 21 days,respectively. When used for prophylaxis following hip or knee surgery, lower dosesare generally prescribed. Doses of rivaroxaban greater than 15 mg must be administeredwith food for proper absorption. Doses of factor Xa inhibitors may need to be adjustedbased on renal and hepatic function.

Since these medications work to slow clotting, the most common side effects arebleeding and bruising, and patients should be educated regarding symptoms thatrequire medical attention (e.g., blood in the urine or stool, symptoms of a hemorrhagicstroke).

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had clarified the route of administration,it is likely the mix-up would have beencaught earlier. Incidentally, ISMP isconsidering the use of tall man letteringfor these drugs because they look verysimilar. We plan to update our tall manletter list early in 2021.

New ASPEN recommendations forin-line filters for PN. The AmericanSociety for Parenteral and Enteral Nutri-tion (ASPEN) published a position paper(www.ismp.org/ext/586) on the appropri-ate use of in-line filters during parenteralnutrition (PN) administration. The recom-mendations in this paper serve as anupdate to previously published recom-mendations. Based on best availableevidence and guidance from scientificand regulatory agencies, ASPEN recom-mends using a 1.2 micron in‐line filter foradministration of total nutrient admixtures(TNAs), dextrose-amino acids admix-tures, and lipid injectable emulsions (ILE).

The safety of using a single 1.2-micronfilter for PN administration is supportedby decades of experience in hospital andhomecare settings and alleviates theconfusion and errors associated withusing two separate filters with differentpore sizes. Simplifying filtering practicescould increase compliance withrecommendations for filter use with PNadministration. For questions, pleasecontact Peggi Guenter, PhD, RN, FAAN,FASPEN; ASPEN Senior Director ofClinical Practice, Quality, and Advocacy(peggig@nutritioncare.org).

Good catch! A physician prescribedolopatadine (PATADAY) 0.2% ophthalmicsolution for a patient to relieve ocularitching and redness associated allergicconjunctivitis. The prescribed instruc-tions for use said to instill one drop intoeach eye twice daily. However, theapproved administration frequency forthe 0.2% solution is once daily—only a0.1% olopatadine ophthalmic solutionincludes an approved administrationfrequency of twice daily. Noticing themismatch between the ordered productconcentration and frequency of admin-

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Newsletter also partially supported by an educational grant from

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ismp.org consumermedsafety.org medsafetyofficer.orgfacebook.com/ismp1twitter.com/ismp_org

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Compared to warfarin, factor Xa inhibitors have a lower incidence of major bleeding,fewer drug and food interactions, and do not require international normalized ratio(INR) monitoring.2 However, warfarin tends to be less expensive for patients thanfactor Xa inhibitors. Also, healthcare providers are probably more familiar with twoagents, phytonadione (vitamin K) and KCENTRA (prothrombin complex concentrate),used to reverse the effects of warfarin, than they are with ANDEXXA (andexanetalfa), a reversal agent approved in 2018 for factor Xa inhibitors. More informationabout Andexxa can be found here: www.ismp.org/ext/604.3

References

World Health organization. Guidance on the use of International Nonproprietary Names1)(INNs) for pharmaceutical substances. Switzerland: 2017:27. www.ismp.org/ext/26

Mekaj YH, Mekaj AY, Duci SB, Miftari EI. New oral anticoagulants: their advantages and2)disadvantages compared with vitamin K antagonists in the prevention and treatment ofpatients with thromboembolic events. Ther Clin Risk Manag. 2015;11:967-77.

Momin JH, Hughs GJ. Andexanet alfa (Andexxa) for the reversal of direct oral anticoagu-3)lants. P&T. 2019;44(9):530-549. www.ismp.org/ext/604

If you would like to subscribe to this newsletter, visit: www.ismp.org/node/138

ISMP Nurse AdviseERR (ISSN 1550-6304) © 2020 Institute for Safe Medica-tion Practices (ISMP). Subscribers are granted permission to redistribute thenewsletter or reproduce its contents within their practice site or facility only. Otherreproduction, including posting on a public-access website, is prohibited withoutwritten permission from ISMP. This is a peer reviewed publication.

Report medication and vaccine errors to ISMP: Please call 1-800-FAIL-SAF(E), or visit www.ismp.org/report-medication-error. ISMP guarantees the confidentiality of information received and respects the reporters’wishes regarding the level of detail included in publications.

Editors: Ann Shastay, MSN, RN, AOCN; Judy Smetzer, BSN, RN, FISMP; Michael Cohen, RPh, MS, ScD (hon),DPS (hon), FASHP; Russell Jenkins, MD; Ronald S. Litman, DO, ML. ISMP, 200 Lakeside Drive, Suite 200, Horsham,PA 19044. Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492.

istration, the pharmacist contacted thephysician. The prescriber clarified theprescription to the intended olopatadine0.1% ophthalmic solution with instruc-tions to instill one drop into each eyetwice daily.

Wakix and Lasix name confusion.Potential name confusion was reportedbetween WAKIX (pitolisant), a drug foradult patients with narcolepsy forexcessive daytime sleepiness (EDS),and LASIX (furosemide), a diuretic.

A medical resident was interacting witha patient via a secure messaging system.The patient asked about a change in hisdose of “Wakix” and whether he shouldget blood tests drawn. The patient hadbeen taking Lasix for some time, and thedose had been changed periodically byhis cardiologist. Because the patienthad made several spelling errors withother words when writing messagesduring this interactive session, theresident assumed the patient had madea spelling error when writing “Wakix”and was instead talking about Lasix.Further questioning revealed that thedrug the patient was inquiring aboutwas Wakix.

The tablet strengths of these medica-tions do not overlap: Wakix is availablein 4.45 mg and 17.8 mg tablet strengths,and Lasix is available as 20 mg, 40 mg,and 80 mg tablets, further decreasingthe likelihood of a mix-up. While no errorresulted in this case, practitioners whocare for patients with narcolepsy shouldbe aware of the risk and educate theirpatients about the possibility of confu-sion. Prescribers should also includethe indication and generic name on allprescriptions for Wakix.

In addition, when communicating viasecure messaging systems, healthcarepractitioners should always verify allmedications discussed with the patient.Pull up the patient’s medical recordduring the interaction. Review eachmedication listed and document anychanges so that the medical record isup to date.

Indication ELIQUIS (apixaban)

SAVAYSA (edoxaban)

XARELTO (rivaroxaban)

ARIXTRA (fondaparinux)*

Stroke and systemicembolism prevention inpatients with non-valvularatrial fibrillation

DVT prophylaxis followinghip or knee surgery

DVT treatment

PE prophylaxis

PE treatment

Reduce risk/reoccurrenceof DVT and PE

Reduce risk of cardio-vascular events in patientswith chronic coronaryartery disease or peripheralartery disease

Table 1. List of factor Xa inhibitors available in the US and their approved indications

*Administered intravenously (IV) or subcutaneously; also, does not follow general “-xaban” namingconvention of other factor Xa inhibitors

Mara Aronson, MS, RN, GCNS-BC, FASCP, CPHQ; AGES: Associationfor Gerontologic Education & Services, Exeter, NHThomas Burnakis, PharmD; Jacksonville, FLHelene M. Burns, DNP, RN, NEA-BC; Jefferson Health, Voorhees, NJStacy Carson, PharmD, BCPS, FISMP; AdventHealth, AltamonteSprings, FLBarbara Chamberlain, PhD, APN, MBA; New Jersey State NursesAssociation, Trenton, NJEileen M. Farley, MSN, RN, NE-BC, CRRN; Bryn Mawr Rehab Hospital,Main Line Health System, Malvern, PAAdina Gutstein, MSN, CRNP, CLS, FNLA, FPCNA; Amryt Pharma,Dublin, Ireland (Boston, MA)Teresa Kerr, RN; Windtree Therapeutics, Inc., Warrington, PAJoanne Kowiatek, RPh, MPM, FASHP; Pittsburgh, PATimothy S. Lesar, PharmD; Round Lake, NYLinda Lilley, RN, MSN, PhD; Elsevier Mosby, St. Louis, MOAnne May, RN, BSN, FAEN; Olney, MDKatie Clark McKinney, PharmD, MS, BCPS, FACHE, FASHP; Universityof Cincinnati Medical Center, Cincinnati, OHNancy McMonigle, MS, RN, NE-BC, CEN, Wellington Regional MedicalCenter, Wellington, FLGinette A. Pepper, PhD, RN, FAAN, FGSA; University of Utah, SaltLake City, UTJoanne Peterson, RN, FISMP; Memorial Hospital/University ofColorado Health, Colorado Springs, COJoanne Farley Serembus, EdD, RN, CCRN (Alum), CNE; DrexelUniversity, Philadelphia, PA

Production of this peer-reviewed newsletter would notbe possible without the assistance of a reliable andtalented Clinical Advisory Board. As 2020 nears an end,we want to thank each of the following members ofthe Clinical Advisory Board for their dedication tomaking this newsletter a valuable medication safetyresource for clinicians.

Special Recognition... Our 2020 Clinical Advisory Board

Advisory Board to the ISMP Board of DirectorsIvyruth Andreica, BSN, PharmD, FISMPRegina Atim, PharmD, MBA, BCMA, CPHIMSAmy Billett, MDIlene Corina, BCPAMark Cziraky, PharmD, CLS, FAHA, FNLARebecca Finley, PharmD, MS, FASHPRyan Haumschild, PharmD, MS, MBARich Kruzynski, RPhTimothy Lesar, PharmDRonald Litman, DO, MLSteven Meisel, PharmD, CPPSAnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, FAANRandi Trope, DO, MBA, FAAP

ISMP StaffMerissa Andersen, PharmD,MPHDamon Birkemeier, PharmDRenee Brehio, MA Michael Cohen, RPh, MS, ScD(hon), DPS (hon), FASHP Rachel Cohen, MS, RD William Cunningham, BSEE,MCSE, CAN Sharon Dicker Michael Gaunt, PharmD Jennifer Gold, MSN, RN Nicole Graser Matthew Grissinger, RPh, FASCP,FISMP

Russell Jenkins, MDArounsavanh Khemdy Rebecca Lamis, PharmD, FISMPRonald Litman, DO, ML Michelle Mandrack, MSN, RNChristina Michalek, BScPharm,RPh, FASHPBennet Ninan, PharmD Jordann Ogle Susan Paparella, MSN, RNJill Paslier, PharmD, CSPAnn Shastay, MSN, RN, AOCN Lisa Shiroff Judy Smetzer, BSN, RN, FISMP Allen Vaida, BSc, PharmD, FASHP

ISMP Board of DirectorsMichael Cohen, RPh, MS, ScD (hon), DPS (hon), FASHPPeter Catalano, MBA, CPAJanice Dunsavage, RPh, MAS Anthony Montagnolo, MSMarcus Schabacker, MD, PhD (chair)

from the staff, Board of Directors, and Advisory Board at the Institute for Safe Medication Practices (ISMP).

We wish you joy, health, and happiness this holiday season!