Pennsylvania Patient Safety Advisory Medication Errors Associated with Documented Allergies ABSTRACT the most common specific factors associated with prescribing errors were a decline in renal or hepatic The selection of appropriate medications and dosages function requiring alteration of drug therapy (13.9%) is dependent upon the availability and review of criti- and patient history of allergy to the same medication cal patient information. Without patient-specific clinical class (12.1%). The two drug categories most frequently information, such as age, weight, allergies, diagnosis, involved in errors related to insufficient patient infor- and laboratory values, healthcare practitioners cannot develop safe and effective treatment plans. As many mation were narcotics and antimicrobials; the most as 18% of serious, preventable adverse drug events serious injuries were due to prescribing these drugs for stem from practitioners having insufficient informa- patients with documented allergies to them. tion about the patient before prescribing, dispensing, A review of data from PA-PSRS reveals more than and administering medications. Review of data from PA-PSRS reveals more than 3,800 reports of cases 3,800 reports in which medications were errone- in which patients received medications to which they ously prescribed for and given to patients who had had documented allergies. Narcotics and antibiotics documented allergies to them. These results are based were the most common medications listed in reports. on the review of the PA-PSRS event type “A. Medica- Types of breakdowns in the communication of allergy tion Errors, 6. Monitoring Errors, c. Documented information include documentation of patients’ aller- Allergies,” as well as other medication error reports gies on paper but not entered into the organization’s identified by PA-PSRS clinical analysts as having computerized order-entry systems, allergy information involved patient allergies. Of the 3,813 reports, 61 not consistently documented in expected locations, (1.6%) resulted in a Serious Event, meaning the organizations’ attempts to list every drug allergen on patient was harmed. Table 1 lists the care areas the wristband, and allergies arising during episodes most cited as the location where the error occurred. of care but not documented in the medical record Although the most frequently cited care area was or communicated to appropriate staff. Strategies to the pharmacy, clearly these problems originate when address problems with patients’ documented allergies orders are written by prescribers in patient care areas. include adding clear and visible prompts in consistent Similar to findings of the study conducted by Lesar and prominent locations; listing patient allergies, as et al.,2 narcotics and antibiotics dominate the top 15 well as a description of the reaction to the allergen, medications listed in reports submitted through PA- on all admission order forms; eliminating the practice PSRS (see Table 2). of writing drug allergens on allergy arm bracelets; and making the allergy reaction selection a manda- An analysis of the reports show that these events fall tory entry in the organization’s order-entry systems. into two broad categories: breakdowns in patient (Pa Patient Saf Advis 2008 Sep;5[3]:75-80.) information and breakdowns in drug information. Patient information helps guide the appropriate Table 1. Care Areas Most Cited in selection of medications, dosing, and routes of admin- Documented Allergy Events istration. This information includes patient-specific NUMBER OF ADVERSE clinical information such as age, weight, allergies, EVENT REPORTS diagnoses, comorbid conditions, and pregnancy sta- CARE AREA (TOTAL N = 3,813) tus, as well as patient monitoring information such Medical/surgical unit 490 (12.9%) as laboratory values, vital signs, and other parameters Emergency department 442 (11.6%) that gauge the effects of medications and the patients’ Ambulatory surgery— 224 (5.9%) underlying disease processes. This information is criti- preoperative and discharge cal because as many as 18% of serious, preventable Telemetry 195 (5.1%) adverse drug events (ADEs) stem from practitioners Operating room 124 (3.3%) having insufficient information about the patient Medical/surgical intensive 78 (2%) before prescribing, dispensing, and administering care unit medications.1 Lesar et al., in a systematic evaluation of Postanesthesia care unit 77 (2%) every third prescribing error detected and averted by Medical/surgical/oncology unit 71 (1.9%) pharmacists in a 631-bed tertiary care teaching hospi- Medical/surgical/cardiac 63 (1.7%) tal, showed that more than 25% of prescribing errors intermediate unit alone were directly associated with inadequate patient Pharmacy 1,042 (27.3%) information, most notably renal and hepatic func- Remaining care areas 1,007 (26.4%) tion, allergies, and pregnancy status.2 In this study, Vol. 5, No. 3—September 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 75 Pennsylvania Patient Safety Advisory Breakdowns in Patient Information irrigation of her operative site done. Following this Errors associated with breakdowns in patient infor- procedure, the nurse noted the penicillin allergy docu- mation, including allergies, diagnosis, comorbid mented by anesthesia. conditions, current medication lists, and labs, involve However, a review of admission notes over a three- breakdowns at each level of the medication-use pro- month period that evaluated the completeness and cess. These errors can occur when practitioners accuracy of drug allergy documentation by medical ■ obtain information from patients, caregivers, or residents, medical students, and primary care nurses other healthcare facilities during the reconciliation showed that approximately 20% of the healthcare pro- process; fessionals failed to document drug allergies in their ■ document the information into paper-based and admission notes. The authors noted that although the electronic records; majority of patients could recall the dosage form of the offending drug, the time that had elapsed between ■ write orders for medications or enter orders into administration of the drug and appearance of symp- computerized prescriber order-entry (CPOE) toms, and how long ago the reaction had occurred, systems; none of this information was recorded by the practi- ■ enter orders into the pharmacy order-entry systems tioners. Therefore, they concluded that incomplete and dispense medications; and documentation of the drug allergy status of patients ■ obtain and administer medications. did not appear to be related to patients’ inability to provide accurate information.4 The majority of When critical patient information, which may or may events submitted through PA-PSRS predominately not be available to the prescriber, is not available in describe situations in which patient allergies have a clear way to pharmacists or nurses at the time of been obtained and documented, yet the patients still dispensing or administering, opportunities for critical received a medication to which they were allergic. double-checks are bypassed. Thus, errors in prescrib- ing may not be detected.3 Documenting allergies, but not including the specific reaction the patient experienced to the medication, Obtaining accurate information from patients can be does not provide all the information necessary to difficult. One case reported through PA-PSRS exem- making therapeutic decisions. Most organizations plifies this issue. obtain a list of medication allergies from patients A patient interviewed during [the preoperative period] upon admission. Yet the most important informa- stated that she had no allergies, but the nursing tion, the actual reaction that occurred from the admission assessment, the anesthesia record, the his- medication that prompted the documented allergy, tory and physical, the emergency room record, and the is rarely included. Knowledge of a patient’s reaction medication [record] indicated that the patient had to penicillin, ranging from an “upset stomach” to an an allergy to penicillin. The patient had an Ancef® anaphylactic reaction, would have a profound effect on practitioners if this information was available. Table 2. Top 15 Medications Involved in A second breakdown in the communication of Documented Allergy Events allergy information occurs when a patient’s allergies are documented on paper but are not entered into NUMBER OF ADVERSE the organization’s CPOE and pharmacy order-entry MEDICATION EVENT REPORTS systems. Prescribers and pharmacists rely on the morphine 303 availability of important patient information, includ- cefazolin (Ancef®, Kefzol®) 213 ing allergies, when entering and screening orders oxycodone and 186 for appropriateness and safety. If this information is acetaminophen unavailable in the organization’s computer order-entry hydromorphone 177 systems, a critical checking mechanism is bypassed, aspirin 176 which increases the risk that medications will be furosemide 106 dispensed to the patient who is allergic to them. In a levofloxacin 98 report submitted through PA-PSRS, this type of break- ceftriaxone 81 down occurred twice with the same patient. ampicillin and sulbactam 78 Patient admitted through the [emergency department (Unasyn®) (ED)] with allergies listed on ED sheet as “VANCO, ampicillin 73 AVELOX, KEFLEX.” The order was written for ketorolac (Toradol®) 70 “Levaquin 500 mg IV q24H.” The patient’s aller- acetaminophen 66 gies were not put into computer by anyone. The ED hydrocodone 63 administered the drug although Levaquin® has tazobactam and piperacillin 53 allergy considerations, considering the patient’s allergy (Zosyn®) to Avelox®. Later, the patient was ordered “vancomy- promethazine 48 cin 1 gm IV Q24h.” The order was processed despite allergy to vancomycin, and the patient developed a Page 76 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 3—September 2008 Pennsylvania Patient Safety Advisory rash as a result. [During the reconciliation process] medical record or communicated to appropriate staff. it is not known [if one] medication caused the rash, As the following case describes, breakdowns in the or both. communication or documentation of new allergies can lead to additional allergic reactions during the When allergy information is not consistently docu- patient’s stay. mented in the expected locations, confusion and problems can arise. It is critical for healthcare prac- Preoperatively, the patient had documented no titioners to be able to find important information known drug allergies. Intraoperatively, the patient about a patient at the time of prescribing, dispensing, was administered Unasyn® (ampicillin/sulbactam) and administering medications. However, allergy 1.5 gm IV and developed hives on her abdomen documentation may be inconsistent and/or appear and chest. Benadryl (diphenhydramine) 50 mg IV in nonstandard locations in the patients’ chart and and Decadron® (dexamethasone) 10 mg IV were other documentation. administered. The patient was admitted to [intensive Patient was prescribed and received Bactrim® follow- care unit (ICU)] and remained intubated. [Later], ing shoulder surgery and subsequently had an allergic the patient was administered Unasyn 1.5 gm IV. reaction, which required intubation and transfer to Halfway through the infusion, the patient developed critical care. The ED record from the previous day stridor and wheezing. identified an allergy to penicillin and sulfa drugs. The There are other breakdowns in the medication use inpatient record and pharmacy records had only peni- system that can lead to errors. The Institute for Safe cillin. The patient’s mother reported only penicillin at Medication Practices (ISMP) identified another error the time admission data was collected. scenario involving inadequate communication of a On nursing assessment, an allergy to penicillin was patient’s allergies.6 A pharmacist could not read the noted. An allergy sticker was not placed on chart per list of patient allergies that a nurse had faxed on a procedure. Ancef® was ordered and administered. new admission, so he accessed the patient’s profile The patient developed an itchy, red rash on arms. from a recent, previous admission and entered the allergies as they appeared on the prior profile. How- As was noted in the December 2005 supplementary ever, the allergies listed there were incomplete. Since Patient Safety Advisory, nearly four out of five (78%) her prior hospital admission, the patient developed survey respondents’ facilities use patient wristbands an allergy to cefazolin. A consulting physician, also to communicate clinical information, including unaware of the patient’s recent allergic response, allergies.5 However, a number of errors have been telephoned an order for cefazolin. The pharmacy associated with the methods used to identify aller- processed the order without detecting the allergy. The gies with wristbands. One problem is that admission cefazolin allergy also was not listed on the medication staff and/or healthcare practitioners forget to apply administration record (MAR) since it was generated the wristband. Another contributing factor is an from the pharmacy computer system. Thus, the nurse organization’s policy to list every drug allergen on the administering the drug did not detect the allergy. The wristband, which is a risky procedure because not patient became hypotensive and unresponsive. The every drug to which a patient is allergic can always be patient’s nurse noticed the adverse reaction, and the listed, as illustrated in PA-PSRS reports. patient was treated with a dose of diphenhydramine, A dressing change was performed on the patient’s recovered, and was discharged the next day. Because peripherally inserted central catheter line. Nurse patients may develop new allergies at any time, medi- performing dressing change utilized Betadine to clean cal records from previous admissions can be used as site. The patient’s chart states that the patient is a reference for allergy history but should be verified allergic to Betadine, but the patient’s allergy brace- with a current list. let did not include Betadine as known allergy. The As noted in an article about verbal orders from the patient [experienced] warmth and flushing of the June 2006 issue of the Advisory, verbal medication face and right arm, which required treatment with orders can result in errors, especially when prescribers Benadryl® 50 mg. do not ask about or are not asked to communicate the Patient was status post hip surgery. Morphine was patient’s allergies and the corresponding reaction.7 administered as ordered for complaints of pain. The Automated dispensing cabinets (ADC) offer the ability patient questioned what pain medication was being for patient profiling. Pharmacists can enter and screen administered. The patient then stated that she gets drug orders against allergies listed in the patient’s pro- “chest pain” from morphine. Allergy band in place file before the medication is removed from an ADC did not list morphine; however, anesthesiology did list and administered. Furthermore, allergy alerts can be morphine as an allergy. programmed to display when a medication to which New allergic reactions that develop during the cur- a patient has a documented allergy is selected for rent hospitalization are as important to capture and retrieval. However, many organizations still use non- document as the patient’s preexisting allergies. How- profiled ADCs. In facilities with nonprofiled ADCs, ever, reports submitted through PA-PSRS illustrate nurses must manually check the medical record or that new allergies are not always documented in the MAR for allergies when retrieving medications from Vol. 5, No. 3—September 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 77 Pennsylvania Patient Safety Advisory a nonprofiled ADC or unit stock. Based on reports may not identify a product that contains a potential submitted through PA-PSRS, this manual check of allergen. When this occurs, a patient may experience the medical record does not always occur. an allergic reaction that requires initial treatment Physician ordered Neurontin® for a patient with a or higher levels of medical care, as illustrated in the listed drug allergy on patient chart and [MAR]. After report below from PA-PSRS. pharmacy hours, the nurse transcribed/verified order The patient had a known allergy to penicillin and and pulled med from night cabinet without any phar- was prescribed Augmentin® (amoxicillin/clavu- macist check of order. Nurse admits to not checking lanic acid). The patient presented to the ED due to for drug allergy and not clarifying with physician. Neu- swelling of her lip and tongue. She was intubated rontin dose was given without any ill effects to patient. and admitted to the ICU with the diagnosis of Unsafe practices with the use of electronic systems angioedema. (e.g., computer order-entry systems, ADCs, point-of- care bar-coding systems) include the use of overrides Once patient information is correctly entered into and workarounds. The use of overrides results in cir- electronic databases, it is possible to screen for any cumventing potentially critical alerts in order to enter drug-allergy interactions. But the electronic screening and process orders more quickly or to obtain and process may not detect potentially significant inter- administer medications before delivery by the phar- actions, as discussed in a May 2007 supplementary macy. For example, a Pennsylvania facility reported Advisory article.8 One study, in which chart reviews the following: were performed on a stratified random subset of all allergy alerts, showed that overrides of drug-allergy Patient had a listed allergy to oxycodone. Order for alerts were common and about 1 in 20 result in Percocet® was prescribed “as needed” for the patient. ADEs, but all of the overrides resulting in ADEs that The nurse used the override feature of the medication were included in the study appeared clinically justifi- dispensing system to obtain the medication, therefore able. The authors stated that the high rate of alert disabling the safety feature to alert for allergies. The overrides was attributable to frequent nonexact match patient developed a rash, which resolved without fur- alerts (in which the drug and allergy had structural ther injury to patient. similarities or were in the same family but were not Administering medications to patients without asking identical) and infrequent updating of allergy lists in the patient for possible past reactions to medications their organization.9 is another breakdown reported through PA-PSRS. Risk Reduction Strategies [Before noon] the patient’s left knee was noted to be oozing. A dime-sized [application of] Betadine® was Healthcare facilities should take steps to ensure that applied to the uppermost part of wound. The patient current and complete allergy information is accu- stated, “I am allergic to Betadine.” The area was rately and clearly collected and readily available to all promptly washed with soap and water. practitioners at the point of care when they are pre- scribing, dispensing, and administering medications. Breakdowns in Drug Information Based on the review of reports in PA-PSRS as well as Breakdowns with critical drug information, lack of observations at ISMP, some suggestions include the available information on prescribing medications, following: lack of knowledge of possible drug-drug contraindi- cations as well as the lack of effective screening for Review all paper and online data collection forms drug-allergy interactions by order-entry systems have to determine the current location in which prac- led to patient harm. One example reported through titioners will document and retrieve complete PA-PSRS discusses a patient who had a documented allergy information, including descriptions of the penicillin allergy, and a prescriber wrote an order reaction(s) (e.g., front of medical record, on the for a medication that had a possible cross allergy to top of order forms, designated MAR locations, the medication listed in the patient’s chart. Cross computer screens, resident assessment forms). This allergies most commonly reported through PA-PSRS location should be standardized and should be include ketorolac with aspirin or nonsteroidal anti- used by all locations in your organization, includ- inflammatory medications (e.g., ibuprofen), as well as ing the ED, operating room, imaging services, and penicillin-derivative antibiotics with Zosyn®, Unasyn, general medical/surgical care areas. Alert staff to or cephalosporins (e.g., cefazolin, ceftriaxone). always refer to these areas for reliable information. Develop a process to make sure updates occur in all A second example of errors associated with drug infor- these areas if the patient’s allergies change. mation concerns combination products that contain two or more active ingredients. When medications Consider adding prompts in consistent locations are prescribed using their brand or trade name (e.g., to document allergy information and include Zosyn, Unasyn), that name does not communicate the clearly visible and prominently placed allergy multiple, active ingredients contained in that product prompts on the top of every page of all prescriber (e.g., piperacillin/tazobactam, ampicillin/sulbactam). order forms (including blank, preprinted, and ver- Therefore practitioners as well as electronic systems bal order forms). Page 78 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 3—September 2008 Pennsylvania Patient Safety Advisory ■ Upon admission to a facility, list patient allergies, ■ Use information reported through PA-PSRS to as well as a description of the reaction to the allergen, identify problem areas, processes, or medications and, if possible, the date that the reaction took to determine the types of events that occur within place, on all admission order forms. Have appro- an individual organization. In addition, measure priate staff consistently transfer this information the use of trigger drugs used to treat allergic reac- obtained on admission to subsequent order forms tions (e.g., diphenhydramine, methylprednisolone, and place the completed forms into the charts so epinephrine) to increase detection of possible that they are readily accessible. This process can preventable ADEs and determine whether there are help visually remind physicians and nurses about other instances of patients erroneously receiving the patient’s allergies when prescribing medica- medications with documented allergies. Collec- tions and/or transcribing a verbal order for a tion of trigger data could be incorporated into medication. the order-screening processes, captured by clinical pharmacists during rounds, or accomplished by ■ If the organization obtains archived allergy infor- those who routinely review patient records, such as mation, establish processes to verify and update quality managers or case managers. this information upon each readmission or patient encounter. Errors have occurred when archived Notes listings are assumed to be complete and correct 1. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis (i.e., new allergy information has become available of adverse drug events. JAMA 1995 Jul 5;274(1):35-43. since the prior data was entered into the computer 2. Lesar TS, Briceland L, Stein DS. Factors related to system). errors in medication prescribing. JAMA 1997 Jan 22-29;277(4):312-7. ■ Establish a forcing function error reduction strategy to make the allergy “reaction” selection a 3. Institute for Safe Medication Practices. Frequent mandatory entry in the organization’s order-entry problems with medication systems noted during ISMP systems for prescribers and pharmacists. hospital evaluations. ISMP Med Saf Alert 1998 Jun 3; 3(11):2. ■ Eliminate the practice of writing drug allergens 4. Pau AK, Morgan JE, Terlingo A. Drug allergy documen- on allergy wristbands. Errors may occur with this tation by physicians, nurses, and medical students. Am J practice if drug names are missed or when small Hosp Pharm 1989 Mar;46(3):570-3. wristbands are used. Confusion may also occur when drug names are abbreviated, misspelled, or 5. Pennsylvania Patient Safety Reporting System. Use of smeared, leading to further risk. In addition, if a color-coded patient wristbands creates unnecessary risk. PA PSRS Patient Saf Advis [online]. 2005 Dec 14 [cited patient has many allergies, multiple bracelets may 2008 Jul 2]. Available from Internet: http://www.psa. be used, increasing the chance that a practitioner state.pa.us/psa/lib/psa/advisories/ may only view one bracelet and not realize there v2_s2_sup__advisory_dec_14_2005.pdf. are more bracelets to check. Instead, have the single red allergy bracelet act as an “alert” to the 6. Institute for Safe Medication Practices. Safety brief. practitioner, identifying at the point of care that ISMP Med Saf Alert 1999 Mar 24;4(6):2. the patient has an allergy, requiring further investi- 7. Pennsylvania Patient Safety Reporting System. Improv- gation of the patient, medical record, and MAR. ing the safety of telephone or verbal orders. PA PSRS Patient Saf Advis [online]. 2006 Jun [cited 2008 Jul 2]. ■ When communicating verbal or telephone medica- Available from Internet: http://www.psa.state.pa.us/ tion orders, prescribers should always ask for the psa/lib/psa/advisories/v3n2june2006/junevol_3_ patient’s allergies and reactions. The receiver of the no_2_article_b_safety_of_telphone_orders.pdf. order should always present this information dur- 8. Pennsylvania Patient Safety Reporting System. Results of ing this process. the PA-PSRS workgroup on pharmacy computer system ■ Provide prescribers, nurses, and pharmacists with safety. PA PSRS Patient Saf Advis [online]. 2007 May 31 education on medication allergies. Educational [cited 2008 Jul 2]. Available from Internet: http://www. efforts need to focus on screening patients for the psa.state.pa.us/psa/lib/psa/advisories/vol._4,_sup._2_ potential of a reaction, recognition of an allergic may_31,_2007/v4_s2_suppl_advisory_may_31_2007. pdf. reaction, and the treatment of serious allergic reactions.10 These efforts should include organi- 9. Hsieh TC, Kuperman GJ, Jaggi T. Characteristics and zation-specific procedures such as the locations consequences of drug allergy alert overrides in a com- to document/find patient allergy information, as puterized physician order entry system. J Am Med Inform well as to access important drug information that Assoc 2004 Nov-Dec;11(6):482-91. includes common allergies, cross allergies, and 10. Institute for Safe Medication Practices. Topical medica- combination drug products that may have implica- tions and allergic reactions. ISMP Med Saf Alert 1996 tions with common drug allergies. Jun 5;1(11):2. Vol. 5, No. 3—September 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 79 ? Pennsylvania Patient Safety Advisory ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following 4. All of the following represent breakdowns or at-risk behav- iors in the communication of patient allergy information examples or come up with your own. EXCEPT? 1. Based on reports submitted to PA-PSRS, during which a. Failing to document the specific reaction the patient phase of the medication-use process do errors involving experienced to the medication breakdowns in communication of patient allergy informa- b. Obtaining a medication by means of an override func- tion originate? tion from an automated dispensing cabinet before a. Dispensing pharmacy review of the order b. Prescribing c. Verifying patient allergies and reactions when commu- c. Administering nicating verbal and/or telephone orders d. Transcribing d. Prescribing medications with insufficient critical patient information (e.g., age, weight, allergies, diagno- 2. Events in which patients were prescribed and given medica- ses, laboratory values) tions to which they had documented allergies fall primarily e. All of the above into two categories. One occurs with breakdowns in drug information. The other is 5. Which of the following risk reduction strategies could a. breakdowns in staff education. reduce the occurrence of adverse drug events related to allergy information? b. breakdowns in quality control. a. Communicating allergy information by documenting c. breakdowns in patient information. drug allergens on patient allergy wristbands d. breakdowns in drug labeling. b. Removing prompts in prescriber order forms that 3. Errors associated with breakdowns in patient allergy infor- would document allergy information mation may occur during each of the following activities c. Establishing processes to verify and update archived EXCEPT? patient allergy information upon each readmission or a. Documenting patient allergy information into paper- patient encounter based and electronic records d. Programming forcing functions into the organization’s b. Obtaining information from patients, caregivers, or computer order-entry systems that would not allow for other healthcare facilities the documentation of “reactions” to allergies c. Entering orders into the computerized prescriber order- entry systems and pharmacy order-entry systems d. Selecting a medication to add to the organization’s formulary Page 80 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 3—September 2008 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 3—September 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 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.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The 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 PA-PSRS program, 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 PA-PSRS program or the Patient Safety Authority, see the An Independent Agency of the Commonwealth of Pennsylvania Authority’s Web site at www.psa.state.pa.us. 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.