Error Alert
Institute for Safe Medication Practices, Horsham, PA
We often look back and reflect on the efforts health care practitioners and patients undertake to improve medication safety. However, we all know that patient safety risks still exist. It would be an incredibly arduous and a near-impossible task to list all the risks associated with medication use that could lead to harmful medication errors. This is often at the heart of questions we receive asking where to start to improve medication safety, and why people frequently resort to playing “whack-a-mole,” addressing risks only after they pop up and become visible after an adverse event.
In this article, we focus on three issues that warrant attention and priority if you have not already taken action to mitigate the risk. They are recurring problems that can result in serious harm to patients.
Selecting the wrong medication after entering the first few letters of the drug name
Entering just the first few letter characters of a drug name, or a combination of the first few letters and product strength, potentially allows the presentation of similar-looking drug names on technology screens. This increases the risk of selection errors or population of a field with an unintended drug. For example, a tragic error occurred in which a nurse entered “VE” into an automated dispensing cabinet (ADC) search field via override and mistakenly selected and removed vecuronium instead of Versed (midazolam).
Other examples of drug selection errors that resulted after entering the first few letters of the drug name include mix-ups between dexmedetomidine and dexamethasone injection; Ambien (zolpidem) and ambrisentan; Briviact (brivaracetam) and Brilinta (ticagrelor); Romazicon (flumazenil) and rocuronium; and tramadol and trazodone. Practitioners seem to read only the first few letters of the first drug name on the list before confirmation bias ensues.
This problem has increased in frequency with the upswing in technology use. In fact, wrong-selection errors may rival or exceed those made with handwritten orders. For example, entering “met” has often led to confusion between methylphenidate, methadone, metolazone, methotrexate, metformin, and metronidazole; and entering “meth10” has led to confusion between methadone 10 mg and methylphenidate 10 mg.
In January 2019, the Institute for Safe Medication Practices (ISMP) released the ISMP Guidelines for Safe Electronic Communication of Medication Information. The guidelines recommend entering a minimum of the first five letters of a drug name during product searches (statement 19) to limit similar names from appearing together on the same screen. ISMP hopes all technology vendors, including electronic health record, pharmacy computer system, and ADC vendors, will consider deploying enhancements in product search functionality in support of our guidelines and to reduce the frequency of menu screen selection errors. Until then, practitioner awareness of this problem may help change personal practice habits and promote the use of at least five letter characters when searching. Indication-based prescribing will also help avoid confusion.
Daily instead of weekly oral methotrexate for nononcologic conditions
Prescribing, dispensing, or administering oral methotrexate daily instead of weekly for nononcologic conditions continues to occur.
A December 2019 ISMP QuarterWatch analysis of inadvertent daily methotrexate administration over 18 months between 2018 and 2019 demonstrated that about half of the reported errors were made by older patients who were confused about the frequency of administration. The other half were made by health providers who inadvertently prescribed, labeled, or dispensed methotrexate daily when weekly was intended.
Another analysis, sponsored by FDA, suggested that up to 4 per 1,000 patients may mistakenly take the drug daily instead of weekly.
More recently, ISMP has identified three additional causes of methotrexate wrong-frequency errors:
- A mix-up between the look-alike, round, yellow tablets of methotrexate and folic acid, the latter of which is often prescribed with methotrexate to lessen its toxicity
- A fatal mix-up between metolazone 2.5 mg, the intended drug, and methotrexate 2.5 mg, caused in part by entering just “met” into the order entry system and selecting the wrong drug from the search menu
- A fatal mix-up between Paxil (paroxetine) 10 mg, the intended drug, and Trexall (methotrexate) 10 mg, caused by mishearing a prescription called into a community pharmacy
ISMP encourages every health care provider to 1) implement computer systems that default to a weekly dosage regimen when entering electronic orders or prescriptions for oral methotrexate, 2) require an appropriate oncologic indication for all daily methotrexate orders, and 3) provide patient and family education about the importance of weekly administration.
To assist with education, providers can give patients and families a free copy of ISMP’s consumer leaflet on oral methotrexate. Whenever possible, prescribers should simplify the dosing schedule to take methotrexate just once a week rather than in several divided doses 12 hours apart. No more than a 30-day supply should be dispensed.
Misheard orders during verbal or telephone communication
In an era of electronic health records and electronic prescribing, one might think that verbal or telephone orders are unnecessary. Yet, certain conditions, such as prescribing a drug during an emergency or sterile procedure or during the current pandemic, may necessitate oral communication of drug therapy, which can be easily misheard.
For example, a verbal order for antithrombin during surgery was mistaken as thrombin by the time it was communicated by phone to the pharmacy. A recommendation for pralidoxime was mistaken as pyridoxine during telephone consultation with a poison control expert. Errors also occurred as a result of unnecessary use of verbal or telephone drug orders, when orders could have been transmitted electronically to prevent confusion.
Reserve verbal or telephone orders for use only during an emergency or when the provider is working in a sterile environment. If use of verbal orders is necessary in the above stated conditions, the receiver should read back (or repeat back during sterile procedures) the drug therapy (drug, dose, route, frequency), spell the drug name, and state the dose in single digits (e.g., one-five for 15). In outpatient and community pharmacy settings, the prescriber (or authorized agent) also should be queried about comorbid conditions, allergies, date of birth, patient weight (if applicable), and purpose of the medication.