Pennsylvania Patient Safety Advisory Safeguarding the Storage of Drug Products ABSTRACT involved in a medication error (e.g., ADC, inpatient A well-organized drug-storage system can reduce the pharmacy, floor stock), this reporting mechanism risk of medication errors. However, events reported does not include fields that facilities can use to to the Pennsylvania Patient Safety Authority describe capture the role that storage may have played with how breakdowns in the storage of medications have medication errors. However, routine review and contributed to drug product mix-ups. More than 200 analysis of medication error events reported to the events have been reported to the Authority from June Authority indicated that the storage of a drug can 2004 through October 2009 that indicate drug stor- play a role in these events. In response, analysts have age as a contributing factor to the event. Analysis created standardized monitor codes that could be reveals that nearly 73% of the events reached the entered into the program database to record/note patient. The most frequently reported event type was those events in which an organization explicitly states wrong drug (99 [46%] of the events reported). Events that drug storage may have played a role in the event. occurred in more than 50 different units, indicating These monitor codes, along with the phrase “next to,” that drug storage issues can and do occur throughout were then used to query the data to identify trends a facility. Strategies to address these problems include and risk reduction strategies. carefully selecting drugs stocked in each patient care From events reported from June 2004 through Octo- area based upon the needs of each patient care unit ber 2009, analysts identified 215 medication error and staff expertise, storing individual medications in a events implicating drug storage as a contributing fac- separate bin or in a bin with dividers between differ- tor to the event. Breakdown of these events by harm ent products, sequestering chemicals currently used score, which is adapted from the National Coordi- for compounding in a section of the pharmacy, and nating Council for Medication Error Reporting and requiring periodic review of storage areas throughout Prevention harm index,5 shows that 156 (73%) of the the organization by a pharmacist or pharmacy techni- events reached the patient (harm index = C to I), and cian. (Pa Patient Saf Advis 2010 Jun;7[2]:46-51.) 53 (25%) of the events resulted in harm significant enough to require additional treatment. The five most common medication error event types Medication use is a complex process and comprises represented 171 (80%) of the 215 events, with the medication prescribing, order processing, dispens- most commonly reported event type being wrong ing, administration, and effects monitoring. Key drug (46%) (see Table 1). “Other” represented the elements that affect the medication-use process1,2 and second largest category of event types (14%). Ten the interrelationships among these elements form (33%) of these events appear to have involved either the structure within which medications are used. The stocking the wrong drug/dosage form in an ADC bin storage of drug products is part of one of the key ele- or removing the wrong drug/dosage form from the ments of the medication-use process. ADC. The “other” events also included error types such as extra dose, monitoring error-documented Implementing a well-organized drug-storage system, as allergy, and unauthorized drug. well as standardizing and limiting the availability of Table 2 lists events by the top five units in which the multiple doses and concentrations of drugs in patient event occurred, representing more than half (53%) of care areas, can reduce the risk of medication errors the total events. The top three units associated with or minimize adverse outcomes should an error occur. Event reports submitted to the Pennsylvania Patient Safety Authority have described how storage of medi- cations in locations including the pharmacy, patient Table 1. Top 5 Event Types Involving Drug care areas, automated dispensing cabinets (ADCs), Storage Issues (n = 171) from June 2004 and anesthesia carts, have contributed to drug prod- through October 2009 uct mix-ups. Other national patient safety groups have % OF TOTAL EVENTS also observed errors, some tragic, related to unsafe EVENT TYPE NUMBER (N = 215) storage conditions. For example, occult blood test Wrong drug 99 46% solutions have been confused with eye drops and Other 30 14 corrosive tissue fixatives, and disinfectants have been Wrong dose/ 22 10 mistaken for oral liquid medications.3,4 overdosage Wrong dosage 11 5 The Numbers form Wrong strength/ 9 4 Although the Authority’s reporting system allows concentration users to indicate the location of the medication Page 46 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory these errors include the medical/surgical unit (21%), (75%) of these events reached the patient. Some of the pharmacy (14%), and the medical unit (7%). these events show problems when multiple concentra- However, events occurred in more than 50 different tions of the same drug are stored in close proximity care areas (e.g., ambulatory surgery, anesthesia, labor in the same storage area. Other events demonstrate and delivery, medical/surgical unit, imaging, operat- problems when multiple-dose containers are stored ing room [OR], pharmacy, psychiatric unit, skilled and used as floor stock rather than pharmacy provid- nursing unit), indicating that drug storage issues can ing patient-specific doses. Examples of events reported and do occur throughout a facility. to the Authority include the following: Patient Care Areas [I] gave patient 10 mg of morphine as opposed to 2 mg of morphine because the boxes of 10 mg were next to Floor Stock the 2 mg of morphine in the drawer. The boxes are While the primary storage of drug products is in the identical in color. I did not immediately sign out the pharmacy or central supply department, there are a medication because I was distracted by other patient number of items that are stored in patient care areas events at the time of medication dispensing. (e.g., medical/surgical unit, emergency department [ED]). Typically, these are frequently used drugs, such The patient was ordered Trandate® 10 mg IV push. as hydration solutions. Other drugs (e.g., opiates) may The nurse removed Trandate multidose vial from also be stored in patient care areas in locked cabinets ACUDOSE [ADC] and administered 10 ml of medi- or ADCs. However, facilities should evaluate what cation (50 mg) IV push. The physician was notified. other drug products are often stored as part of floor IV fluids were administered, and the patient was stock. For example, high-alert medications (e.g., con- monitored. centrated electrolytes, labetalol injection), especially There have been occurrences of harmful events involv- those that require intravenous (IV) admixing or com- ing floor stock storage of drugs reported elsewhere. pounding, should not be stored in patient care areas, One such event occurred when an anesthesiologist as these can cause serious harm when used in error. from an OR placed a vial of atracurium, a neuromus- The classic example of error-prone floor stock storage cular blocking agent (NMBA), in the refrigerator near of a drug involved concentrated potassium chloride vaccine vials of similar appearance.12 Seven infants vials. In the 1980s and 1990s, many patients were were subsequently administered atracurium subcu- seriously harmed, and a number of them died, as taneously instead of hepatitis B vaccine. The infants a result of errors that occurred when concentrated developed respiratory distress; five infants recovered, potassium chloride vials were stored in patient care one sustained permanent injury, and another died. areas.6-9 Sometimes the errors in these cases were due The Institute for Safe Medication Practices (ISMP) to knowledge deficits about the dangers of rapid IV noted that NMBAs had never been available as floor administration of concentrated potassium or, more stock in the nursery. often, were mental slips or wrong drug selection Night Closet when choosing a vial of medication. Patient safety organizations called for the removal of concentrated In hospitals where 24-hour pharmacy services are potassium chloride vials from patient care areas, and not available, nurses need access to limited sup- in 2002, the Joint Commission published a National plies of essential medications during off hours. To Patient Safety Goal (NPSG) mandating accredited help safeguard this need, the Joint Commission has hospitals follow suit. Limiting access to this drug has established a medication management standard that reduced fatal errors.10,11 requires that accredited facilities limit after-hours, nonpharmacist access to supplies of medication to a Information contained in 97 (45%) of the 215 events secure location or a night/weekend cabinet outside reported to the Authority indicated that the events in- the pharmacy.13 Additionally, medications that are volved drug products stored as floor stock. Seventy-three made available should be limited to only those drugs approved by the hospital. Despite these standards, some facilities continue to allow nurses access to the Table 2. Top Five Care Areas Associated entire pharmacy inventory after hours. The accessibil- with Drug Storage Issues (n = 113) from ity and variety of medications available, as well as a June 2004 through October 2009 potential lack of an independent double check of the % OF TOTAL original order to the obtained medication, contribute CARE AREA NUMBER EVENTS (N = 215) to medication errors. Medical/surgical unit 45 21% Information contained in 88 (41%) of the 215 events Pharmacy 30 14 indicated the involvement of drug products that were Medical unit 15 7 stored in some type of night closet or after-hours phar- Acute specialty 12 6 macy area. Sixty-seven (76%) of these events reached rehab unit the patient. The most frequently reported event type Emergency 11 5 for cases involving night closet storage was wrong department drug. This event type accounted for 39 (44%) of these Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 47 Pennsylvania Patient Safety Advisory events. Two examples of wrong drug errors submitted medications are separated in the satellite pharmacy, to the Authority are as follows: but they ended up next to each other on the counter, Order for Xopenex 1.25 mg nebs three times a day. and the incorrect bottle was selected. Xanax 1.25 mg was pulled from night locker and When a nurse retrieved Senokot®, she realized that given to patient. the medication in the syringe was clear; Senokot is Lovastatin 20 mg by mouth ordered. Lovenox 30 mg dark brown. The syringe was returned to the phar- subcutaneous was removed from pharmacy night box macy, and the correct medication was dispensed. An by the supervisor. The nurse gave the medication. investigation revealed that the medication was sodium bicarbonate, which is stored next to the Senokot. While none of the reported events describe incidents of patient injury, serious harm and even death can A patient was ordered Neomycin®. When the nurse occur when safeguards are not in place for night went to give the medication, [the nurse] noted that closet storage and access. In 2007, ISMP reported a naproxen had been sent. The pharmacy was contacted, case in which a patient presented to a critical access and the correct medication was sent. The medications hospital extremely short of breath. His physician had were stored near each other in pharmacy ([in] alpha- prescribed an IV dose of furosemide.14 However, the betical [order]), and the pharmacy technician had pharmacy was closed, so a nurse entered the secured inadvertently selected the wrong med. Pharmacist did section of the pharmacy to obtain the drug. She mis- not check the med prior to leaving the pharmacy. takenly selected a vial of potassium chloride instead In the book Medication Errors, Cohen and Smetzer of furosemide, both of which were kept on adjacent describe how unsafe storage of mivacurium, an shelves just above the floor. She took the vial to the NMBA, next to the antibiotic metronidazole resulted care area, withdrew the medication, and adminis- in several patients receiving mivacurium by mistake.16 tered it to the patient. An erroneous association of One patient died while three others went into respira- potassium on the label with the potassium-excreting tory arrest. A review of the event found that look-alike, diuretic likely resulted in the nurse’s failure to recog- foil-wrapped, premixed IV products had been stored nize the error until she went back to the pharmacy to next to one another in the bulk IV storage area. document removal of the drug. The patient died as a Several other factors contributed to the mix-up and result of this error. eventual administration of mivacurium, including the following: (1) the addition of mivacurium to the Pharmacy hospital formulary was not communicated to all staff; The pharmacy department, including the central (2) prior to mivacurium being added to the formulary, pharmacy and any satellite pharmacies, is the primary metronidazole was the only premixed IV product with location where drugs are purchased, stored, prepared, a foil overwrap; and (3) the products in the bulk IV and dispensed. This results in a large volume of drug storage area were organized alphabetically, and mivacu- products being stored in one area of the facility. Also, rium was placed next to metronidazole. many pharmacy departments order from a single wholesaler that offers preferred, low-cost products. Refrigerator For example, a wholesaler may purchase all hydra- Refrigerators, in both pharmacy departments and tion and frozen premixed IV products from a single patient care areas, are locations of drug storage. manufacturer that uses a consistent brand appear- Refrigerators present unique challenges to safeguard- ance, layout, and label design for their products. This ing drug product storage, such as limited space or increases the risk of look-alike products being stored lacking built-in discrete pockets or bins. Also, depend- in the pharmacy.15 ing on the location of the refrigerator, it may be used Thirty (14%) of the 215 storage-related events impli- to store manufacturer-packaged products for floor cated pharmacy as location of the error, making stock use, as well as patient-specific or patient-labeled pharmacy the second most often reported location products. This increases the risk that a healthcare of these errors (see Table 2). Often, the facilities that practitioner may select the wrong drug (e.g., a vial of reported these events identified, within the error rapid acting insulin rather than an insulin mix) or description, that side-by-side storage of the drug retrieve the wrong patient’s medication (e.g., the drug products contributed to the event. Examples include labeled for the patient in bed 100-A instead of the the following: drug for the patient in bed 100-B) from a refrigerator. How much space is available in the refrigerator, as A nurse received a syringe containing a red liquid, well as the facility’s decisions about what products to and the label read that the medication was “Dilantin store and how to organize them, will impact the safety 60 mg.” The nurse knew that Dilantin® was an of refrigerator storage. orange liquid and not red. The syringe was brought to pharmacy, and she obtained the correct medica- From events reported to the Authority, analysts found tion (Dilantin). The medication in the original the following examples of refrigerator-related drug syringe was phenobarbital. Pharmacy investigated storage. and found that the medications were positioned next Patient was ordered “Ativan 1mg IV prn HS.” Label to each other, and the names looked the same to the was prepared correctly by pharmacist, and the order pharmacy tech (phenobarbital and phenytoin). These was filled incorrectly by a technician with famotidine Page 48 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory 20 mg vials. Both medications are stored in the refrig- ■ Review the list of items that staff from each patient erator in the pharmacy. The error was caught when the care area can order manually or automatically drug reached the floor. The pharmacist was alerted, through materials management. Ensure that phar- and the correct medication was then dispensed. maceutical products cannot be provided without A TPN [total parenteral nutrition] additive was to prior pharmacy agreement and supervision.19 be famotidine 20 mg. A vial of fosphenytoin ■ Ensure that drugs stocked in patient care areas are 100 mg/2 ml was accidentally used in the compound- available in the least number of doses, concentra- ing. The error was caught during required review by tions, and forms that will meet essential patient the pharmacist. The reporter noted that both vials needs between replenishment (not to exceed are similar in appearance, and both are a 2 ml size. 72 hours).18 The medications were stored next to each other in the ■ Ensure that drugs, including emergency medi- refrigerator due to a temporary move of the IV room cations, stocked in patient care areas are in outside the pharmacy. Now that the IV room has age-specific, ready-to-administer, unit-dose forms returned, these two products are again segregated into (i.e., are not stored in bulk containers).18 two different refrigerators. Many examples have also been published by national ■ Ensure that NMBAs are not available as floor stock patient safety organizations. For example, a respiratory and/or in ADCs (except in OR/anesthesia stock).18 therapist in a pediatric intensive care unit obtained Based on the results of the 2004 ISMP Medication what he thought was a sterile water vial to prepare a Safety Self-Assessment, NMBAs were available as nebulizer treatment.12 Fortunately, he noticed that floor stock outside the OR in 80% of hospitals he had grabbed a vial of the NMBA atracurium that responding; of the respondents, 59% said that someone had inadvertently returned to a respiratory when available outside the OR, these drugs were box in the refrigerator. The atracurium and sterile not sequestered from other floor stock items or water vials both had similar purple color accents. labeled with auxiliary warnings.20 Errors related to unsafe storage of medications in ■ When possible, dispense NMBAs from the refrigerators have caused serious patient harm and pharmacy as prescribed for patients. Outside the death. One such case involved intrathecal injection pharmacy, limit access to these agents to the OR, of an undiluted dose of rifampin to a 32-year-old ED, and critical care units where patients can be woman.17 The physician ordered vancomycin 20 mg properly ventilated and monitored. intrathecally each evening and rifampin 450 mg IV ■ When NMBAs must be available as floor stock, each morning for a central nervous system staphy- have the pharmacy department assemble the vials in lococcal infection. The pharmacy placed both the a sealed box with warnings affixed as noted below. evening dose of vancomycin and the morning dose of Sequester the boxes in both refrigerated and nonre- rifampin in syringes next to each other in the refrig- frigerated locations. erator. A medical student removed both syringes, thinking that, together, they contained a single dose ■ Place vials, bags, and syringes of drug products in of intrathecal vancomycin, and administered the a sequestered bin for immediate pharmacy pick-up medication. He also did not notice the label on the after the drug has been discontinued or the patient rifampin syringe that stated the medication need to has been discharged or transferred. be diluted in 250 mL of fluid prior to administra- ■ Use strategies of product separation and segrega- tion. The patient experienced nystagmus, nausea, and tion to improve safe drug storage. Store individual vomiting, and within a few days developed left hemi- medications in a separate bin or in a bin with paresis and required mechanical ventilation. dividers between different products. Label each section in a manner that clearly identifies the drug Risk Reduction Strategies stored within. Healthcare facilities should take steps to safeguard the storage of drug products throughout the institution. ■ If using ADCs, convert the large matrix drawers This includes storing and dispensing medications to drawers with locking lids, which enables limit- according to manufacturers’ guidelines for tem- ing drug removal to the product selected on the perature, light, and expiration date. Consider the ADC screen. strategies described below, which are based on a ■ Isolate medications used by respiratory therapists review of events submitted to the Authority, as well as into one location in the ADCs (e.g., one matrix observations at ISMP and in the literature. drawer), and restrict therapist access to those Patient Care Areas drawers only. ■ Carefully select drugs stocked in each patient care ■ Review guidelines for the safe use of ADCs, such area by considering the needs of each patient care as those from ISMP (available at www.ismp.org/ area and the expertise and familiarity of staff with Tools/guidelines/ADC_Guidelines_Final.pdf) specific drugs, with the risk of error associated with and the American Society of Health System Phar- each drug, and with the age and diagnoses of typi- macists (available at www.ashp.org/DocLibrary/ cal patients being treated on the units.18 BestPractices/AutoITGdlADDs.aspx), to enhance Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 49 Pennsylvania Patient Safety Advisory organizational practices related to ADC stocking, can reduce the risk of serious errors. ISMP Med Saf Alert drug dispensing, storage, and administration. 2002 Sep 4;7(18):1. ■For additional strategies to safeguard the use of 5. National Coordinating Council for Medication Error ADCs, review the September 2005 Patient Safety Reporting and Prevention (NCC MERP). NCC MERP Advisory article “Problems Associated with Auto- index for categorizing medication errors [online]. 2001 mated Dispensing Cabinets.” [cited 2009 Sep 15]. Available from Internet: http:// www.nccmerp.org/medErrorCatIndex.html. Pharmacy ■ Remove and discard unnecessary hazardous bulk 6. Institute for Safe Medication Practices (ISMP). Potas- sium accident made public in Boston. ISMP Med Saf chemicals from the chemical/compounding stor- Alert 1996 Feb 28;1(4):2. age area, particularly those that have not been used within the last 6 to 12 months. Ensure permanent, 7. Institute for Safe Medication Practices (ISMP). KCL in secure labeling of hazardous chemicals. Apply floor stock? Be ready for accidental IV potassium over- large cautionary labels to products as appropriate doses. ISMP Med Saf Alert 1996 Apr 24;1(8):1. (e.g.,“MUST BE DILUTED,” 8. Institute for Safe Medication Practices (ISMP). Safety “FOR COMPOUNDING USE ONLY”). brief. ISMP Med Saf Alert 1997 Mar 26;2(6):2. ■ Segregate those chemicals currently used for com- 9. The Joint Commission. Medication error prevention— pounding, and continue to store them in a fully potassium chloride [online]. Sentinel Event Alert 1998 sequestered section of the pharmacy. Feb 28 [cited 2009 Oct 06]. Available from Internet: ■ Segregate and store electrolytes for IV compounding http://www.jointcommission.org/SentinelEvents/ together in one location: the IV preparation area. SentinelEventAlert/sea_1.htm. ■ Store sterile water bags away from medication sup- 10. The Joint Commission. Making an impact on health plies. Never allow IV compounding products to care [online]. Sentinel Event Alert 2000 Apr 21 [cited 2009 Oct 06]. Available from Internet: http:// leave the pharmacy’s sterile compounding area. Seg- www.jointcommission.org/SentinelEvents/ regate these solutions, and store them with warnings SentinelEventAlert/sea_13.htm. to not distribute them outside the pharmacy.19,21 11. The Joint Commission. Sentinel event trends reported ■ Sequester and affix warning labels to vials of by year—updated through 2008 [online]. [cited 2009 Oct NMBAs stocked in the pharmacy. Be sure the warn- 06]. Available from Internet: http://www. ing labels do not obscure the vial label in any way. jointcommission.org/NR/rdonlyres/ ■ Maximize the pharmacy’s ability to provide patient- 67297896-4E16-4BB7-BF0F-5DA4A87B02F2/0/ specific unit-dose solid and liquid medications se_stats_trends_year.pdf. (either commercially obtained or prepared by the 12. Institute for Safe Medication Practices (ISMP). Paralyzed pharmacy) throughout the institution. by mistakes: preventing errors with neuromuscu- ■ Ensure that all medications are stored in individual lar blocking agents. ISMP Med Saf Alert 2005 Sep labeled bins within easy access (and visualization) 22;10(19):1-3. for all staff. 13. The Joint Commission. Standard MM.05.01.13. In: ■ Investigate implementing technologies such as 2009 Hospital Accreditation Standards. Oakbrook Terrace barcode on dispense in the pharmacy to reduce the (IL): Joint Commission Resources; 2009. risk of selecting the wrong medication from stock. 14. Institute for Safe Medication Practices (ISMP). Potas- Quality Processes sium may no longer be stocked on patient care units, but serious threats still exist! ISMP Med Saf Alert 2007 ■ Require periodic review by a pharmacist or Oct 4;12(20):1-2. pharmacy technician of storage areas in the orga- nization, including the pharmacy and patient care 15. Drug labeling and packaging—looking beyond what areas (e.g., ED, radiology, OR, medication rooms) meets the eye. PA PSRS Patient Saf Advis [online] 2007 to identify potential storage issues. Sep [cited 2009 Oct 6]. Available from Internet: http:// patientsafetyauthority.org/ADVISORIES/ Notes AdvisoryLibrary/2007/sep4(3)/Pages/69b.aspx. 1. Institute for Safe Medication Practices (ISMP). Spotlight 16. Cohen MR, Smetzer JL. Risk analysis and treatment. In: on the key elements of the medication-use system, part Cohen MR, ed. Medication errors: causes, prevention, and 1. ISMP Med Saf Aler Com/Amb 2003 Oct;2(10):3-4. risk management. Washington (DC): American Pharma- 2. Institute for Safe Medication Practices (ISMP). Spotlight ceutical Association; 1999. on the key elements of the medication-use system, part 2. 17. Institute for Safe Medication Practices (ISMP). Acciden- ISMP Med Saf Alert Com/Amb 2003 Nov;2(11):3-4. tal administration of IV meds intrathecally. ISMP Med 3. Institute for Safe Medication Practices (ISMP). Safety Saf Alert 1998 Sep 23;3(19):1. brief. ISMP Med Saf Alert 1998 Jan 14;3(1):2. 18. Institute for Safe Medication Practices (ISMP). 2004 4. Institute for Safe Medication Practices (ISMP). Involving ISMP medication safety self assessment for hospitals non-clinical departments in patient safety discussions [online]. 2004 [cited 2009 Sep 15]. Available from Page 50 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory ? Internet: http://www.ismp.org/selfassessments/ 20. Smetzer J, Cohen M. Preventing errors with neuromus- Hospital/2004Hosplrg.pdf. cular blocking agents. Jt Comm J Qual Patient Saf 2006 19. Institute for Safe Medication Practices (ISMP). Water, Jan;32(1):56. water, everywhere, but please don’t give IV. ISMP Med 21. Institute for Safe Medication Practices (ISMP). Worth Saf Alert 2003 Jan 22;8(2):1-2. repeating: avoiding mix-ups between sterile water and sodium chloride bags. ISMP Med Saf Alert 2007 Dec 13;12(25):3. ? Self-Assessment Questions The following questions about this article may be useful for 4. All but one of the following are effective strategies to internal education and assessment. You may use the following reduce the risk of medication errors involving drug storage. examples or come up with your own. Select the INEFFECTIVE strategy. 1. Four of the following five areas were included in a list of a. If using automated dispensing cabinets (ADC), orga- the top five locations associated with errors involving the nize stock using large matrix drawers. storage of drug products. b. Isolate medications used by respiratory therapists into Select the location that was NOT reported as one of the one location in the ADCs (e.g., one matrix drawer), top five locations. and restrict therapist access to those drawers only. a. Acute specialty rehab unit c. Ensure that drugs stocked in patient care areas are b. Emergency department available in the least number of doses, concentra- c. Medical/surgical unit tions, and forms that will meet essential patient needs between replenishment periods. d. Medical unit d. Apart from the pharmacy, limit access to neuromuscu- e. Operating room lar blocking agents to the operating room, emergency 2. The most frequently reported type of medication error department, and critical care units where patients can involving the storage of drug products is: be properly ventilated and monitored. a. wrong dosage form. e. Require periodic review by a pharmacist or pharmacy b. wrong dose/overdosage. technician of storage areas in the organization, includ- c. wrong drug. ing the pharmacy and patient care areas. d. wrong strength/concentration. 5. A nurse received a syringe containing a red liquid and the e. wrong time. label read “Dilantin 60 mg.” The nurse knew that Dilan- tin® was an orange liquid and not red. The medication in 3. All of the following are true about access to drug products the original syringe was identified as phenobarbital. The after the pharmacy is closed EXCEPT: pharmacy’s investigation found that the medications were a. Nearly 41% of events related to drug storage that were positioned next to each other in the pharmacy, and the reported to the Authority involved drug products that names looked the same to the pharmacy technician (phe- were stored in some type of night closet or after-hours nobarbital and phenytoin). pharmacy area. Select the appropriate strategy to help prevent this event b. The Joint Commission permits facilities to allow non- from reoccurring. pharmacists access to the pharmacy after hours. a. Ensure that drugs stocked in patient care areas are in c. Roughly 76% of events reported to the Authority age-specific, ready-to-administer, unit-dose forms. involving drug products stored in some type of night closet or after-hours pharmacy area reached the patient. b. Educate pharmacy staff that these two products will be stored next to one another. d. Medications that are made available for staff access after hours are limited to those approved by the c. Store therapeutically similar products together on phar- hospital. macy shelves. e. The accessibility and variety of medications available d. Implement barcode on dispense technologies in the after hours, as well as a potential lack of an indepen- pharmacy. dent double check of the original order, contribute to e. Apply large cautionary labels that read “MUST BE medication errors. DILUTED” or “FOR COMPOUNDING USE ONLY” to hazardous bulk chemicals as appropriate. Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 51 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 2—June 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.