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Medication Safety Alert! June 2000

This column draws primarily on US experience and includes, with permission, material from the ISMP Medication Safety Alert! biweekly bulletin, published by the Institute for Safe Medication Practices (ISMP), Huntingdon Valley, Pennsylvania, USA.


With the support and assistance of Michael Cohen and ISMP, the Institute for Safe Medication Practices Canada (ISMP Canada) is founded. It is an independent nonprofit organization established for the collection and analysis of medication error reports and the development of recommendations for the enhancement of patient safety. Like its sister organization, the Institute for Safe Medication Practices in the US, ISMP Canada intends to serve as a national resource for promoting safe medication practices throughout the health care community in Canada.

The Institute will work collaboratively with healthcare practitioners and institutions, schools, professional organizations, the pharmaceutical industry, and regulatory and government agencies to provide education about adverse drug events and their prevention.

ISMP Canada will work collaboratively with CSHP and its Medication Error Task Force to bring together a successful Canadian medication error reporting system.

ISMP Canada presently is developing a plan for implementing a suite of programs and activities including a web enabled medication error reporting system, medication safety alert newsletters, and medication safety self assessment tools. Pharmacy practitioners are encouraged to send information about medication-related errors, "near-misses" or medication error prevention strategies to ISMP Canada in one of the following ways:

(1) email: (2) fax to ISMP Canada 905-886-0803 or (3) send reports through the ISMP Canada's web site. All identifying information will be held in strict confidence.

For more information on ISMP Canada, please visit the web site:

Medication Returned from the Nursing units

While many Canadian hospitals have adopted a unit dose distribution system, some are still dispensing individual prescriptions and/or are using ward stock. A sixty-three year old was prescribed Carbamazepine 300 mg for seizure control. Approximately one week later, he developed severe drowsiness, confusion and respiratory depression requiring transfer to an acute care hospital. Investigation into all the medications he was taking revealed that his individual prescription vial of Carbamazepine 200 mg tablets contained quite a few primidone 250 mg tablets. Primidone is a pre-cursor of phenobarbital which, when taken, can cause respiratory depression. (analysis of blood was positive for phenobarbital in this patient).

Both Carbamazapine 200 mg tablets and Primidone 250 mg tablets are generic products, are white in color and have almost identical sizes. Although the carbamazepine tablets are marked with "200" and the primidone tablets are marked with "250", it is very difficult to distinguish between them. Apparently, some nurses could have added a previous supply of medication together with the current supply of the same medication. These two drugs look so similar that they were accidentally mixed together. Pharmacy staff was also allowed to use the "recycled" medications from the nursing units. In this case, the returned medication from the floor (which contained both Carbamazepine and Primidone tablets) was labeled as Carbamazepine 200 mg tablets and the pharmacy staff dispensed it as Carbamazepine to this patient without realizing it also contained Primidone 250 mg tablets. Fortunately the patient's condition improved over the next few days and he suffered no serious sequelae.


  1. Re-enforce the hospital policy that different vials or bottles of the same medication MUST NOT be poured together to a single container, neither at the nursing units nor in Pharmacy.
  2. Develop a pharmacy policy that no returned or recycled medications are to be dispensed to another patient or used as a floor stock. If that imposes an economic issue, reuse only the very expensive medications, but discard all other returned drugs.
  3. Pharmacy should avoid, when possible, purchasing drugs that look almost identical. These usually come from a single generic manufacturer.
  4. If possible, Pharmacy should be consistent with the brand of a particular medication so that nurses, technicians and pharmacists become familiar with its appearance and are more able to notice slight differences.
  5. Purchase, when possible, unit dose packaged drugs even if the distribution system is traditional. This provides an inherent "check" in the system.
  6. A unit dose distribution system should be instituted so that this type of error can be prevented.
  7. In the community setting, patients should be advised of the risks associated with transferring medication from one prescription vial to another.

The special feature described below is taken directly from ISMP Medication Safety Alert! Volume 5, Issue 6, March 22, 2000.)

Is automation the universal remedy for preventable adverse drug events?

Problem: Can automation - computerized physician order entry (CPOE), electronic medication administration records (MARs), bar code systems, and more - eliminate virtually all medication errors, or will it instill a false sense of security? Automated medication systems have been heralded in recent reports to the government (Institute of Medicine and Quality Interagency Coordination Task Force Reports), promoted in the legislature, and mandated by some health systems (Veterans Affairs) and purchasers (Leapfrog Group). While such technology is pivotal to reducing errors, too often, healthcare leaders mistakenly believe that the immediate effects of automation alone will ensure the safety of their medication systems.

Early adopters of the newest technology have reported significant barriers to successful implementation, new sources of error, and major infrastructure changes that have been necessary to accommodate the technology. Further, while new technology always introduces the opportunity for unanticipated errors, some vendors have marketed their products without sufficient testing or the ability to fully implement it on site. As a result, frustrated practitioners have taken shortcuts or added complexity to the medication system to circumvent or cure technology problems. Some examples follow.

Because there is not a uniform bar code that is required on all products, the error-prone process of in-house packaging and coding may be necessary when implementing bar coded drug administration. Even with bar coded drugs, nurses may be unable to scan the drug at the bedside if it must be removed from its package for preparation (removing specific doses from vials/ampuls, wasting part of a prefilled morphine syringe under the eye of a witness, etc.). Furthermore, in these cases, the bar code may not match the dose ordered and administered. Hard-to-scan codes or insensitive scanning devices have led to drug administration outside the bar code system or the use of bar code "cheat sheets" (frequently-used labels affixed to a sheet of paper for easy scanning) to circumvent the system. Also, if a drug is prescribed or entered into the pharmacy computer in error, bar code systems will only help to get the wrong drug to the correct patient or the ordered drug to the wrong patient.

The order entry process with many CPOE systems currently on the market is error-prone, time-consuming, and lacks important screening capabilities to alert practitioners to unsafe orders. As a result, prescribers may bypass the order entry process totally and encourage nurses, pharmacists, or unit secretaries to enter written or verbal drug orders. Some CPOE systems are separate from the pharmacy system, which requires double entry of all orders. This may result in electronic/computer-generated MARs that are derived from the CPOE database, not the pharmacy database, often causing frequent discrepancies and extra work for nurses and pharmacists. Also, the MAR that is generated from the CPOE system may be used without pharmacy review. If electronic MARs are not readily available at medication stations and at the patient’s bedside, or if their use is cumbersome or confusing, nurses often use handwritten notes or computer-generated care plans, which do not clearly present drug information, to guide drug administration. Afterward, nurses may forget to document drug administration in the electronic MAR. Additionally, automation does little to enhance medication systems that are already plagued with problems. For example, using robotics for drug dispensing in systems without timely order entry and interfaces for transfers, admissions, and discharges, is fraught with error. Placing automated dispensing cabinets in systems with slow turnaround time for medications dispensed from pharmacy will likely lead to increased stock and unsafe administration of many first doses without pharmacy screening.

David U is the Pharmacy Manager, Centre for Addiction and Mental Health, Queen's St. Site, Toronto. David can be reached at