Episode #55 Be on the Look-out for Look-alike Vials

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

I hope that you caught our show last week where we started talking about medication safety and look alike vials. Plus, the APSF Social Medial Manager provides some audio clips for some exclusive content. We are going to continue the conversation this week.

Before we dive further into today’s episode, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

If you are on twitter, then I hope that you were able to check out the #lookalikevials hashtag and if not, what are you waiting for? Go check it out. This is a very important threat to patient safety.

And now, let’s return to our review of the article written by the late Ron Litman, whose life and career had great impact in this area, “Important Medication Errors and Hazards Reported to the ISMP National Medication Errors Reporting Program During 2021” from the June 2021 APSF Newsletter.

To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then scroll down looking in the left hand column and the 6^th one down is our featured article today. Last week, we discussed the prescribing, dispensing, and administering extended-release opioids to opioid-naïve patients and the use of smart infusion pumps with dose error-reduction systems in Perioperative Settings.

Today, we are going to start off with a conversation about oxytocin administration. Do you work on the labor and delivery floor and take care of OB patients? Vials of oxytocin may look a lot like vials of Ondansetron including the vial size and the green cap and this has led to medication administration errors. Check out the article for a picture of these lookalike vials and I will include a link in the show notes as well. Administration of oxytocin as a bolus may lead to uterine hyperstimulation and ultimately fetal distress, uterine rupture, and emergent cesarean section. The 2020 ISMP analysis revealed that oxytocin errors has caused maternal, fetal, and neonatal deaths. One of the associations with this medication errors was the look-alike vials and label confusion. This is what that picture depicts since the brand Pitocin vials look similar to Ondansetron vials that are available from several manufacturers with similar green caps. The label confusion with oxytocin  is due to 1, 10, and 30ml oxytocin vials that display the 10USP units/ml prominently with the total volume in the vials at the bottom of the label so staff thought that each vial only contained 10 units of oxytocin total in the vial. This resulted in reported 10-fold dosing errors.

Another important consideration with oxytocin ordering occurs due to the order entry such that a search for “OXY” could lead to an order for oxycodone instead of oxytocin or searching for “PIT” could lead to Pitressin (which is a discontinued brand of vasopressin) instead of Pitocin. Verbal orders have been associated with similar drug name confusion leading to error in drug ordering. Incorrect administration of oxytocin has occurred due to incomplete labels or failure to label nurse-prepared oxytocin solutions. In addition, oxytocin solution bag may be confused with a bag of crystalloid fluid or magnesium up on the OB floors.

As you can see, there are a lot of considerations for safe administration of oxytocin. In order to address this situation, institutions may require 5 letters for a drug search in the electronic system and use only pharmacy dispensed oxytocin solution bags that are labeled and come in a standardized concentration. The next step is to make sure that the oxytocin vials as well as the pre-mixed infusions are clearly labeled especially the amount of drug per total volume. Barcode scanning technology should be used for stocking automatic dispensing cabinets and during any preparation and administration of oxytocin infusions.  Last week, we talked about smart infusion pumps with drug error-reduction systems and this is one of the times to use that system – anytime you are infusing an oxytocin solution. Once the infusion has been completed or discontinued, make sure to discard the infusion bag.

Our next situation involves the hazards associated with positioning infusion pumps outside COVID-19 Patient’s rooms. This is a newer situation that has come out of special patient care situations during the COVID-19 pandemic. Infusion pumps with extension tubing may have been positioned outside of patients’ room in order to conserve PPE, decrease staff exposure, and allow the pumps to be heard and responded to quickly for patients with Covid-19. The extension sets required for this positioning will change the volume of priming fluid, the infusion pump flow rates, and the time for medications and solutions to reach the patient after starting a pump and changing the dose. Patients may also receive an unintended bolus of medication that was remaining in the extension tube due to flushing the tubing. There is also a concern for a time delay for occlusion alarms at low flow rates or excessive occlusion alarms at high flow rates. Staff also need to be mindful of the extension tubing and necessary electrical cords that are tripping hazards in the patients’ rooms and it is vital to ensure that the extension tubing does not become tangled or disconnected from the patient. The space between the patient and the infusion pump may affect the ability to perform barcode scanning of the medication prior to starting therapy and independent double checking of the infusion may be challenging as well. Going forward, it is important to weight the risks and benefits of positioning the infusion pumps outside of the room for patients with COVID-19. If the decision is made that the benefits outweigh the risks, and the pumps are positioned outside of the patient room, it is important to evaluate the process and incorporate the ECRI recommendations from the special report, “Large-Volume Infusion Pumps—Considerations When Used with Long Extension Sets outside Patient Rooms to Help Reduce Staff PPE Use” which was published on April 1, 2020. I will include a link in the show notes as well. The recommendations include:

• Periodic infusion pump rounds in the hallway to verify the accuracy of the fluids and medications infusing as well as the pump settings by the patient’s nurse
• Ensure that the tubing is connected appropriately and it is not a tripping hazard
• Develop a temporary process so that barcode scanning and/or independent double checks may continue to occur prior to medication administration. For example, the patient’s name, birthday, and hospital identification barcode on the IV pole or close to the pump.
• Finally, when pumps are returned to the standard positioning inside the patient’s room, it is important to stop using the temporary measures and use the standard verification processes at the institution.

Our next medication safety is combining or manipulating commercially available sterile products outside the pharmacy. The ISMP conducted a 2020 survey to look at admixture of medications outside the pharmacy. This may lead to medications errors since it is often done for emergency situations by staff without formal training with serious procedural deviations. Sterile injectable medications prepared outside of the pharmacy include medications for IV push, intermittent infusions, IM injections, and continuous IV infusions, and these medications may be prepared by nurses, physicians, and anesthesia professionals. The survey respondents reported lack of training as a concern related to this practice and other concerns included lack of space and time, for example moving quickly during an emergency, labeling issues, mixing medications by memory instead of using a written protocol, interruptions and distractions, and maintaining sterility and accuracy of medication dose and concentration. In addition, about one-third of the respondents reported awareness of medication error in the past year especially during the preparation process. This survey provides insight into the practice of preparation of admixtures outside of the pharmacy and highlights the need for institutions to limit this practice. Increased patient safety may require increased use of pharmacy and manufacturer prepared, ready-to-use products. I will include a link to the survey that you can use at your institution for an internal review of this practice. Does this occur at your institution? To find out, check out the survey and share with the anesthesia professionals at your institution. The results may reveal unique considerations and help you to develop a plan going forward. Improved patient safety will require reduced need and frequency for admixture outside of the pharmacy. This is an important topic and we will have to check back in next year.

Let’s move on to the next topic and it is Wrong Route Errors with Tranexamic Acid which has occurred with intraspinal injection rather than intravenous injection. The APSF published a notice about this in September 2020 after this safety threat reached the level of the National Alert Network. This is the only medication error that was on the ISMP 2019 List of Top 10 Medication Errors and Hazards. This is such an important topic right now because we do not want to see this on the 2021 list especially since accidental intraspinal injection of tranexamic acid can cause serious complications with a 50% mortality rate. The situation occurs when tranexamic acid is injected into the intraspinal space instead of the local anesthesia medication. This is once again associated with look-alike vials since bupivacaine, ropivacaine, and tranexamic acid may be in similar sized vials with the same blue cap color. There are pictures in the article that you should check out. Plus, when the vials are positioned upright in a medication drawer, it is impossible to notice the difference from the cap color. Recently, the FDA reported that it will examine the tranexamic acid labeling to highlight the IV route only for administration and add a risk of wrong route administration errors to the warning.

What can we do right now to improve patient safety and prevent this deadly error? Healthcare professionals may need to purchase these medications from different manufacturers with different vials and caps or in alternate preparations including pre-mixed bag or pharmacy-prepared syringes or infusions. Tranexamic acid is available in a premixed bag of 1g in 100mls or the pharmacy may be able to prepare a mini-bag of tranexamic acid for administration so that it does not need to be drawn up out of a vial. Do not store the vials upright in a drawer since the  vial labels should always be visible. Also, Tranexamic vials should always be stored away from local anesthetics and additional labels on the caps may be necessary to distinguish the medications and highlight that tranexamic acid can only be administered by the IV route. This is the time to use the barcode scanning before dispensing and administration of these drugs.  Finally, the NRFit syringes and connectors may be used for local anesthetics to administer for spinals or epidurals and help to prevent IV medications from being administered via the intraspinal route.

The 2020 list of common medication errors from the ISMP highlights important patient safety threats. We need to remain vigilant anytime we administer medications to help keep patients during anesthesia care. Consider implementing some of the strategies that we discussed last week and today to help keep your patients safe.

Last week, Amy Pearson discussed the December 2020 ASA Statement on Labeling of Pharmaceuticals for Use in Anesthesiology last week and I will include a link in the show notes as well. The statement starts with a call to action that the most important thing about the design and use of labels for syringes, infusion bags, and medication containers must be the reduction of medication errors.  The next section includes the requirements for labeling which includes the generic name and concentration of the medication as well as the date and time and preparer’s initials. You may want to include the patient’s name and the route of administration as well. There are 9 reserved colors for classes of drugs commonly used in anesthesiology including Induction agents, Benzodiazepines and their antagonists, Neuromuscular blockers and their antagonists, Opioids and their antagonists, Anti-emetics, Vasopressors and hypotensive agents, Local anesthetics, Anti-cholinergic agents; and Beta-blockers. The standard labeling is black on the specific background for most agonist agents and black on the white-striped specific background for most antagonist agents. Succinylcholine and Epinephrine are special medications with text that is the specified color on a black background bar on the top of a label. There are many more important recommendations when it comes to labeling medications. I am going to highlight one more and that is the position of the label on the syringe. When syringes labels are placed incorrectly, they may be difficult to see or read and can lead to a syringe swap or administration dose drug error.  The recommended label placement should be directly below the gradation lines so that the scale, medication name, concentration, and dose are all easy to see and read during administration of the medication. Check out the full statement for additional recommendations to help reduce medication errors and keep patients safe in the OR.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  You can find us on twitter, Instagram, Facebook and LinkedIn!  See the show notes for more details and we can’t wait for you to tag us in a patient safety related tweet or like our next post on Instagram, like us on Facebook, or connect with us on LinkedIn!! Follow along with us for the latest news and updates in perioperative and anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation