Issues Legislative Committee Meeting

July 9, 2009

Quality / Medication Errors / Safety Issues

Safety/Medication Errors:

“Mix-up between lactated Ringer’s and oxytocin”
ISMP Medication Safety Alert May 2009, Vol 7, Issue 5

A woman in advanced labor received an unspecified amount of IV oxytocin after a nurse mistakenly picked up an oxytocin infusion instead of a bag of lactated Ringer’s intended for hydration. The nurse set the infusion pump to deliver a maintenance flow rate. The oxytocin infusion quickly affected the patient’s contractions, causing significant pain as well as deceleration of the baby’s heart rate. The nurse noticed the error while she was squeezing the bag to speed up the rate of infusion and facilitate intrauterine resuscitation. The infant was delivered, having a low Apgar score and required care in the NICU to treat respiratory distress. The mother sustained a third degree laceration.

To avoid mix-ups in the hectic environment as labor and delivery, the following should be reconsidered:

• Distinguish with bold labels
• Separate and organize products
• Restrict access – avoid bringing unneeded medications/solutions into the LDR rooms.
• Provide clear handoffs – require repeat back and encourage clarifying questions
• Use bar-coding technology

“Lyrica-Lopressor Mix-up”
ISMP Medication Safety Alert May 2009, Vol 7, Issue 5

A patient with a past medical history of atrial fibrillation was admitted to a hospital with an order for LOPRESSOR. However, the physician’s handwriting was poor and the order was misinterpreted and dispensed as LYRICA. The patient received 3 doses of Lyrica and experienced atrial fibrillation that was temporary related. A nurse recognized the error.

Matching the drug’s indication to the patient’s health condition is the best way to avoid confusion between products with look-alike names.

“Misidentification of alphanumeric symbols in both handwritten and computer-generation information”
ISMP  Medication Safety Alert July 2, 2009, Vol. 14, Issue 13

Problem – The English language uses the Latin alphabet with 26 letters and a numeric system with 10 numerals. Problems may arise during written or electronic communication because of similarities in appearance of the alphanumeric symbols we use. For example the lower case l looks exactly like the numeral 1. The upper case O looks like the numeral 0.  Mistaken letters and numerals pay a large part in errors when reading handwritten drug names and doses.

Safe Practice Recommendations:
Lower case letters or mixed case letters – Lower case letters in general offer more differentiation than upper case letters. Mixed case letters also provide better distinction among letters than using all upper case or all lower case letters.

• Block printing on lightly lined forms – Encourage prescribers to use block printing for handwritten orders.
• Symbolic differentiation – This is another way to distinctively convey a symbol’s meaning – for example in Europe it’s common to see a zero written with a dash through it to differentiate it from the letter 0.
• Space between the drug name and dose – Allow adequate space between the drug name and the dose on handwritten prescription, printed prescriptions and order set, and electronic formats such as computer selection screens, computer-generated medication labels and records, printed forms  and shelf labels.
• Drug and dose make sense – When reading an order, determine if the dose is within a recommended range and available in the strength prescribed. If not, follow-up with the prescriber may be necessary to clarify the order.

Supply Chain Standards – GS1/HSCSC

GS1 Healthcare US

AHRMM continues to support GS1 standards for the healthcare supply chain and has representation on all of the workgroups including the Global Location Number (GLN) Work Group, the Global Trade Item Number (GTIN) Work Group, the Global Data Synchronization (GDSN) Work Group, the Traceability Work Group, the Adoption and Implementation Work Group, and the GS1 Healthcare US Leadership Team. The "Standardization. Stat!" video promoting awareness of the issues of standardization in the healthcare supply chain has been posted the AHRMM website and will be aired at the AHRMM Conference Opening General Session. The Leadership Team and GLN and GTIN work groups continue to work to ready the industry for adopting universal data standards and eliminating custom account numbers by 2010 (GLN) and custom product numbers by 2012 (GTIN). The plan involves the adoption of the GLN for standardized account/location identification and the GTIN® for standardized product identification by all healthcare providers and suppliers. This industry-wide initiative to adopt GS1 standards for account/location and product identification will help to ensure that the correct products are delivered to correct locations at the correct time – creating a safer, more efficient, and less expensive supply chain. To further educate and provide awareness to supply chain professionals, a GS1 overview flyer will be included in attendee tote bags. AHRMM has dedicated an entire track to standards at AHRMM09.

The Adoption and Implementation Work Group finalized the C-Suite collateral piece which presents the benefits of data standards at a high level to assist with the “top down” approach to getting the standards adopted by healthcare providers. The C-Suite collateral piece will be included in the AHA Leadership Summit tote bag given to over 1,100 healthcare C-Suite professionals.

The next GS1 Healthcare US Work Group Forum is in October however work groups meet weekly by phone.