Marion General Hospital (MGH) is a 165-bed acute care hospital in North Central Ohio and is a member of the OhioHealth system. At MGH, our medication safety team analyzes hospital practices to identify potential points of failure. In addition, the team encourages staff to report potential errors, close calls, and actual errors. An online reporting system makes it easy for staff to report errors, and includes a section where employees can suggest changes that will prevent recurrences. Employees who report close calls are given a token that is good for a meal in the hospital cafeteria. Managers are encouraged to thank staff who report errors, and are trained on “just culture.”

Building a Medication Safety Team
The medication safety team is led by a medication safety pharmacist, and includes staff developers, staff nurses, nurse managers, the pharmacy director, a pharmacy technician, and information system analysts. The vice president of medical affairs represents the medical staff, and the vice president of operations represents hospital leadership.

Additionally, there is an organization-wide medication safety team covering the entire OhioHealth system, which consists of eight wholly owned hospitals and nine affiliates, as well as a number of home health and outpatient locations. The physician that chairs this medication safety team also is a pharmacist. An OhioHealth medication safety pharmacist serves on MGH’s medication safety team, which allows for cross-
pollination of ideas between facilities.

In addition to leading the medication safety team and working as a staff pharmacist, the role of the MGH medication safety pharmacist is to review all MGH medication error reports and adverse drug reaction reports and develop preventive measures. Errors that occur at other facilities can provide significant insight into error prevention, thus the medication safety pharmacist regularly conducts literature reviews, paying particular attention to the ISMP Medication Safety Alert! and The Joint Commission’s Sentinel Event Alert. It is important for the medication safety pharmacist to work closely with other staff members—and with the pharmacy inventory control technician, in particular—to identify potential points of failure. While MGH currently does not have bedside bar code medication scanning, we will implement this additional level of safety in 2011. Many of the safety initiatives we have developed resulted from not only studying our own error reports, but from proactively addressing concerns raised by staff members and reviewing errors that have occurred at other facilities.

Magnesium Sulfate Infusions
A 2004 report in the American Journal of Maternal Child Nursing1 reported 52 cases of accidental magnesium sulfate overdose in the labor and delivery setting. Some of these errors were fatal or caused permanent harm to the mother. Many of the errors resulted from the unintended rapid infusion of the entire contents of a liter bag containing 40 grams of magnesium sulfate. In some cases, the magnesium bag was confused with plain IV solution, and the rate was increased on the wrong bag. In other cases, the error resulted when a loading dose was given from a large-volume bag, but the rate was not turned down after the loading dose was completed. Alert MGH staff also reported that premixed magnesium 1 gram, 2 gram, and 4 gram “piggyback” bags were very similar in appearance to each other, thus increasing the potential for an error.

To prevent magnesium errors at MGH, the medication safety team adopted the following strategies:

• Elimination of 1 gram premixed bags and standardization of preprinted
• order sets to 2 gram doses in non-labor and delivery settings.
• Standardization of magnesium in the labor and delivery setting to premixed products.
• Replacement of 40 gram/liter premixed bags with 20 gram per 500 mL bags for two reasons: First, the bags are now differentiated by size. That is, 500 mL magnesium bags look much different than liter bags of lactated ringers solution. Second, if an accidental rapid infusion does occur, the patient will only receive half as much magnesium as they would have before this strategy was adopted.
• Stock 4 gram/50 mL premixed bags in the labor and delivery area for use in bolus doses. To prevent confusion with 2 gram premixed bags, the MGH inventory control technician labels each 4 gram bag with a large, colorful “Magnesium sulfate *4 GRAM*” sticker as soon as the bag arrives in the pharmacy (see Image 1).
• Revise preprinted order sets to match the new concentrations.
• Program smart infusion pumps to match the premixed concentrations, and to limit the infusion to safe rates.

Preventing IV Administration of Epidural Solutions
Epidural infusions often contain bupivacaine or other local anesthetics, which can cause fatal cardiac arrhythmias if given intravenously. In 2007, The Institute for Safe Medication Practices reported five deaths and several near-fatalities from accidental intravenous infusions of epidural solutions. In one case, a 16-year-old woman in labor accidentally was given bupivacaine and fentanyl intravenously instead of epidurally. As a result, the mother died, although the infant survived.

MGH uses epidural infusions for laboring patients and for post-operative pain control. Nerve block infusions containing bupivacaine are used to control post-operative pain in some patients who are poor candidates for epidurals. Epidural and nerve block solutions dispensed by the pharmacy are typically in 250 mL bags, which look much like the bags used for some antibiotic infusions. It is critical to keep these local anesthetic solutions from being given intravenously.

MGH uses the following processes to prevent confusion between epidural solutions/nerve block infusions and intravenous solutions:

• Ancillary labels are applied to epidural and nerve block infusions before they leave the pharmacy. On the front, a patient label is applied, along with a large blue label containing the word “EPIDURAL.” On the rear, the epidural infusions have a fluorescent green label listing the ingredients (see Image 2).
• Differentiation: In the labor and delivery setting, premixed bottles of ropivacaine are used for epidurals. Ropivacaine is possibly less cardiotoxic than bupivacaine, and bottles of epidural solution are unlikely to be confused with bags of IV solution.
• Pharmacy review: Epidural and nerve block infusion solutions are only available to nurses after the order has been reviewed by a pharmacist.
• Pumps: A separate infusion pump is used for epidural and nerve block infusions and its maximum rate is limited to 20 mL/hour.
• Tubing: Epidurals and nerve block infusions are connected to the patient by distinct yellow tubing. This tubing has no ports, which eliminates the risk of another medication being piggybacked into the epidural site.

Adult and Neonatal Phytonadione Injections
Phytonadione (Vitamin K1) is often used in adults to stop bleeding or to reduce elevated INRs. In neonates, a much smaller dose is given to prevent hemorrhagic disease of the newborn. This product comes in two sizes: 10 mg/1 mL (for adults), and 1 mg/0.5 mL (for neonates). The two ampoules are similar in size and appearance and are easily confused. MGH employees were concerned about possible errors, and anecdotal reports from other hospitals described cases where the 10 mg ampoules were mistakenly stocked in neonatal areas.

MGH’s pharmacy inventory control technician suggested a switch to a prefilled 1 mg phytonadione syringe. The syringe looks much different from the ampoules (see Image 3), thus greatly reducing the risk of an error. When refilling the nursery stock, pharmacy employees work from a list that specifies a 1 mg syringe. The nurses in the neonatal area were quick to embrace this change, and it has been effective in preventing errors.

Continuous Infusions vs. Intermittent Medications
Intravenous admixtures that should be infused over 12 to 24 hours sometimes resemble a “piggyback” medication that should be infused over 30 to 60 minutes. For example, a diltiazem infusion prepared in a 100 mL bag looks much like cefepime 2 grams in 100 mL. Should a nurse confuse the two products and infuse the diltiazem over 30 minutes, severe hypotension could result.

Intravenous infusions that look like piggyback medications are differentiated with ancillary labels on the front of the bag (see Image 4). These labels are applied by the pharmacy technician who prepares the admixture, and verified by the pharmacist who checks the product. Ancillary labels are applied to:

• Midazolam
• Norepinephrine
• Amiodarone
• Diltiazem
• Pancuronium
• Phenylephrine
• Insulin
• Lorazepam

Heparin Challenges

MGH stocks heparin premixed bags in two strengths. The first, containing 25,000 units in 500 mL (50 units/mL) is intended for therapeutic use (e.g., treating patients with deep vein thrombosis). The second concentration, containing 2,000 units in one liter (2 units/mL) is intended to maintain patency of arterial lines.

The need for two concentrations of a single product creates a risk of error. If a nurse selects the lower potency product for a patient who should get a therapeutic dose, the patient’s condition will go untreated. If the higher concentration is selected for a patient who needs the lower concentration, bleeding may result.

The MGH medication safety team decided to incorporate the words “Heparin drip bag” and “Heparin flush bag” into the automated dispensing cabinet (ADC) listing for these medications. The two products are placed on different shelves in the machines, and therapeutic heparin is only available to inpatient nurses after it has been approved by a pharmacist.

Differentiating Hydroxyzine Injection from Hydralazine Injection
Hydroxyzine, an antihistamine, has a very similar name to hydralazine, which is used to treat hypertension. Both are hydrochloride salts, and both come in 1 mL vials with small lettering that is difficult to read. If hydralazine is given when hydroxyzine is ordered, a dangerous drop in blood pressure may occur. If the reverse mistake happens, hypertension would go untreated.

Rather than storing both products under their generic names, MGH stores hydralazine under “A” for Apresoline, and uses Tall Man letters (hydrOXYzine and hydrALAzine) on the shelf labels. The ADC selection screens and refill forms include both the brand and generic names, i.e., hydrOXYzine (Vistaril) and hydrALAzine (Apresoline).

Conclusion
While no strategy is foolproof, these efforts have effectively reduced the incidence of errors at our institution. MGH staff looks forward to the implementation of bedside bar code scanning software, which will provide another layer of defense against these dangerous, potential errors.

Reference
1. Simpson KR, Knox GE. Obstetrical accidents involving intravenous
magnesium sulfate. Am Jour of Maternal Child Nurs. 2004;29(3):161-169.

Dan Sheridan, MS, is a medication safety pharmacist at Marion General Hospital in Marion, Ohio. Dan, a former director of pharmacy, also serves as a clinical advisor to ISMP and is a past recipient of the ISMP Cheers Award.