Kate Kelly, PharmD

Most error-reduction effortsbegin in response to a seriouserror. Individuals and practicesites have become accustomed to reactingto an error after it has occurred.Unfortunately, only then do they considerhow to prevent the same error frombeing repeated.Would it not be useful tobe able to predict the types of errors thatcould occur and 

All too often, error potential is notincluded in decisions about which medications,devices, or technology to purchase.Instead, decisions are guided bycost, third-party formulary restrictions,contractual agreements with purchasinggroups or vendors, and pharmaceuticalmarketing efforts. Input and evaluationfrom those who will be using the productsmay not be sought, and error potentialmay not be considered ahead of time.The ultimate result is unforeseen safetyissues and errors once the product is inthe hands of clinical users or health careconsumers.

Failure Mode and Effects Analysis(FMEA) systematically identifies areas ofpotential failure and gauges what theeffects would be before an error actuallytakes place. This 

process canbe employed to examine the use of newmedications and products, as well as thedesign of new services and processesthat may affect work flow. FMEA is bestemployed 

to purchase and implementation,so that preemptive action canbe taken.

To cite just one example, FMEA couldbe used to assess the potential for errorwith new medications when they are firstmarketed or before they are prescribedor added to your inventory:

A process-flow diagram wouldbe designed. Then the ways the intendedproduct would be prescribed would beexplored. Who would prescribe it and forwhich patients? What clinical patientinformation would be important beforethe product is prescribed? How would itbe procured, stored, and used, fromacquisition through dispensing andadministration? Who would prepare anddispense it? What information would needto be given to the patient or caregiver?How would the product be administered?

Potential failure modes (ie, howand where systems and processes mayfail and what can go wrong) would beidentified while considering how the productwould be used. Questions to be askedwould include the following: Does thedrug name look or sound like anotherdrug name? Would a similarly spelled drugname be listed in close proximity to theintended product on computer orderentry screens? Does the package labelclearly express the strength or concentration?Would the product be stored near, orcould it be mistaken for, another similarlypackaged product? Are dosing parameterscomplex?

For example, an FMEA performed onquetiapine (Seroquel) might have predicteda high likelihood of mix-ups with nefazodone(Serzone). These 2 medicationsare likely to be prescribed by the sametype of physician and for patients withsimilar diagnoses; are available in overlappingdosage strengths; often areadministered at the same frequency; andare likely to be stored together and toappear on computerized lists in closeproximity, alphabetically by brand name.Although Serzone is no longer marketed,these types of errors are still likely,because generic formulations of nefazodoneare available and may be prescribedas "Serzone." 

For each failure mode, staffmembers would then determine the likelihoodof making an error, as well as thepotential consequences. What wouldhappen to the patient if the drug weregiven at the wrong dose, at the wrongtime, or by the wrong route? What wouldhappen if a patient received the wrongmedication or if the wrong patient receivedthe medication?

Staff members would considerthe severity of the outcome and identifyany preexisting processes in place thatcould help eliminate or detect the errorbefore it reached the patient. Eachprocess would then be evaluated for itseffectiveness, based on what was learnedin previous steps. For example, wouldobtaining additional patient information orusing computer alerts, bar coding, or adouble-check process catch these errorsevery time? Numerical values could beassigned to determine the likelihood ofthe occurrence, its severity, and thechance that it would be detected beforecausing patient harm.

If failure modes reveal errorswith significant consequences, actionswould be taken to prevent the error,detect it before it reached the patient, orminimize its consequences. Suchactions might include improved communicationof orders by listing the indicationon prescriptions or differentiatinglook-alike products by ordering themfrom different manufacturers or by storingthem separately.

Although industries outside of medicinehave developed elaborate FMEA scoringsystems to rank items for action, a simplifiedFMEA process as described abovecan be an efficient, proactive risk managementtool. 

ISMPMedication Safety Alert!Community/Ambulatory CareEdition.

Articles

FMEA Can Help Prevent Errors

The Institute for Safe MedicationPractices (ISMP) has received numerousreports of mix-ups involving metronidazoleand metformin. In one report, a familypractice physician in a communityhealth center prescribed metformin 500mg bid to a newly diagnosed patient withdiabetes who did not speak English.When the patient returned to his physician'soffice a few months later, hebrought his medications with him, asrequested. His physician quickly noticedthat metformin was missing. Instead, thepatient had a prescription bottle labeledas metronidazole, with directions to take500 mg twice a day. The prescription hadbeen refilled several times. Luckily, thepatient's diabetes had remained stable,and he seemed to suffer no adverseeffects from 2 months of unnecessaryantimicrobial therapy.

The physician notified the pharmacy ofthe error and asked the pharmacist tocheck the original prescription. It hadbeen written clearly and correctly formetformin. Upon further investigation,the pharmacist found that the computerentry screen for selecting these medicationsincluded "METF" (for metformin)and "METR" (for metronidazole). Apparently,one of the pharmacy staff membershad entered "MET" and selectedmetronidazole instead of metformin.

In another community pharmacy, thesame mix-up happened twice, on successivedays. In one case, metformin wasinitially dispensed correctly, even thoughthe prescription had been entered intothe computer incorrectly as metronidazole—again, when the wrong mnemonicwas chosen. The pharmacist who filledthe prescription clearly understood thatthe physician had prescribed metformin,so he filled the prescription accordingly.He failed to notice the order entry error,however, because he did not comparethe prescription vial label with the manufacturer'slabel. Unfortunately, the initialorder entry error led to subsequent erroneousrefills of metronidazole, as statedon the pharmacy label.

In the second mix-up at this pharmacy,bulk containers of the medication wereavailable from the same manufacturer,both with similar highly stylized labels.Thus, confirmation bias contributed toselection of the wrong drug. After reading"MET" and "500" on the manufacturer'slabel, the staff member believed thathe had the correct drug.

Unit-dose tablets also can be problematic,because the label information is verysmall and contains bar codes, adding totheir similar appearance. In a hospitalpharmacy, unit-dose tablets of metronidazole500 mg and metformin ER 500mg were accidentally mixed together inthe metronidazole storage bin. This errorresulted in dispensing metformin insteadof metronidazole. Fortunately, a nurse recognizedthe error before giving a patientthe wrong medication. Both were genericproducts, although the brand name versionsof metformin (Glucophage) andmetronidazole (Flagyl) also are available.

Mix-ups involving metronidazole andmetformin could be serious, consideringthe different indications and the potentialfor drug interactions. Prescribers shouldbe sure that patients are aware of themedication's purpose and should includethis purpose on the prescription. Considerprogramming computer order entryscreens to display the specific brandnames along with the generic nameswhenever the "MET" stem is used as amnemonic, or apply tall-man lettering tothe drug names. In addition, pharmacistscould consider writing the correspondingbrand name on generic manufacturers'containers. Purchase these medicationsfrom different manufacturers, and underlineor highlight the unique letter charactersin the drug names.

During the dispensing process, drugnames listed on written prescriptionsshould be matched with pharmacy labelsand manufacturers' products. As an additionalcheck, match the National DrugCode number of the product with thatwhich appears in the computer databaseand subsequently on the printed pharmacylabel.

Verify the purpose of the medicationwith the patient. Because metformin isused to treat a chronic condition, andmetronidazole is more likely to be usedfor an acute condition, outpatient refillsfor metronidazole are less common and,therefore, deserve a second look. We atISMP have asked the FDA to add thesedrugs to the list of nonproprietary namesthat would benefit from the use of tallmanletters.

The reports described here were receivedthrough the USP Medication Errors ReportingProgram, which is presented in cooperationwith the Institute for Safe Medication Practices(ISMP). ISMP is a nonprofit organization whosemission is to understand the causes of medicationerrors and to provide time-critical errorreductionstrategies to the health care community,policy makers, and the public. Throughoutthis series, the underlying system causes ofmedication errors will be presented to helpreaders identify system changes that canstrengthen the safety of their operation.If you have encountered medicationerrors and would like to report them, youmay call ISMP at 800-324-5723 (800-FAILSAFE)or USP at 800-233-7767 (800-23-ERROR). ISMP's Web address is www.ismp.org.

Metronidazole and Metformin Prone to Mix-ups

When prescribing, dispensing, oradministering formoterol fumarate(Foradil Aerolizer) or tiotropium bromide(Spiriva HandiHaler), consider the distinctpossibility that these medications maybe swallowed mistakenly rather thaninhaled through their accompanyingdevices. Formoterol fumarate is a longactingbeta

agonist used in the treatmentof asthma and chronic obstructivepulmonary disease (COPD), and tiotropiumbromide is an anticholinergic bronchodilatorused for COPD. Each medicationis available as a dry powder within acapsule, and the capsules are packagedin blister cards. When used correctly, thecapsule is removed from the blister cardand placed into the inhaler device. In thedevice, the capsule is punctured to allowthe medication to be dispersed into thelungs as the patient inhales through theinhaler mouthpiece.

Because capsule dosage forms usuallyare associated with oral administration,formoterol fumarate and tiotropium bromidehave been swallowed by mistake.The Institute for Safe Medication Practices(ISMP) has received numerousreports describing situations wherepatients have received these medicationsby the ineffective oral route. Mostof the reports have come from hospitalsand long-term care (LTC) facilities. A fewreports, however, have involved communitypharmacy patients.

Reports have cited the following contributingfactors:

—Prescriptionsmay be communicated ambiguously. Forexample, a prescription with the instructions"Foradil one capsule orally every 12hours" was received and dispensed by apharmacy. These instructions led thepatient to believe that the medicationwas to be swallowed. Also, medicationadministration records (MARs) may listthese medications along with other oralmedications. Such instructions oftenbegin with the phrase "1 capsule," leadingnurses to think that the product is anoral medication.

—Patients and practitionerswho are unfamiliar with this dosage formmay mistakenly administer the medicationorally.

—These products may bestored along with other oral medicationsin patient homes or in medication drawersand automated dispensing cabinets inLTC facilities. If the inhaler device is separatedfrom the capsules, caregivers arelikely to assume (due to the dosage form)that the capsules are to be swallowed.

—Packaging issimilar to that of other oral unit-dosemedications, and blister labeling is inadequateto protect against oral use.

To prevent similar errors with thesemedications, consider the following:Products should be ordered andentered into computer systems as"Foradil Aerolizer" and "SpirivaHandiHaler" to better distinguish themedication when it prints out on apatient's MAR or pharmacy label.

Instructions for both patients and staffmembers must clearly express the needfor the medication to be inhaled: forexample, "Inhale the contents of onecapsule every 12 hours using Aerolizer."Avoid using instructions that begin with"One capsule?" or that include the word"oral," which may be misinterpreted. If aprescriber's instructions are nonspecific(eg, "1 capsule bid" or "use once daily"),pharmacists should express the instructionsin a manner that clearly states howthe medication is to be used.

Shortcuts could be programmed intocomputer systems to ensure that theseproducts are ordered and dispensedwith the proper instructions. For example,if the word "Spiriva" is entered in theinstructions field, the phrase "Inhale thecontents of 1 capsule once daily usingHandiHaler" would be printed.

Auxiliary messages stating "FOR USEONLY WITH INHALER. DO NOT SWALLOWCAPSULE" or "FOR INHALATION ONLY" should print out prominently on MARs.Similar auxiliary labels could be placedon boxes and blister labels to help differentiatethese capsules from other oralmedications that may be stored in thesame place. Otherwise, these productsshould be stored separately from oraldosage forms.

Patients, caregivers, and staff membersmust be educated regarding theproper administration of these medicationsbefore they are dispensed oradministered. Training kits containing aninhaler device, placebo capsules, andpatient education materials are availablefrom each manufacturer.

Capsules should be stored in the boxprovided along with the inhaler device.Do not dispense the capsules separately.In LTC facilities, put the patient's name onthe inhaler device to ensure that it isreturned to the correct patient's box ofmedication.

The manufacturers of both productsare aware of the errors that haveoccurred, and we at ISMP have askedthem to place a warning on the blistercards. The FDA also is aware of our concerns.These errors should serve as areminder that health professionals needto be very clear in their verbal and writteninstructions. 

Capsules for Inhalation May Be Mistaken for Oral Capsules

The Institute for Safe MedicationPractices has received reports from 2 differentoutpatient infusion clinics whereinfliximab (Remicade) and rituximab(Rituxan) were confused with eachother. In both cases, the reporters implicatedsimilarities in the products' genericnames. Both are monoclonal antibodiesthat are stored in the refrigerator, anddoses could possibly overlap. Remicadeis used in a variety of autoimmune disorders,including rheumatoid arthritis andCrohn's disease, whereas Rituxan is usedin non-Hodgkin's lymphoma. Both havewell-known, serious adverse drug reactions—even fatalities—associated withtheir use.

Prescribers should include the brandand generic names, as well as the indication,when ordering these products. Ifthis information does not appear on theprescription, pharmacists and nursesshould verify the medication and theindication with prescribers before dispensingor administering the drug.Consider placing "name alert"stickers onthe products and separating the productsin the refrigerator.

The following 2 errors involving lisinopriland lovastatin were reported by thesame pharmacy. In the first case, bothlisinopril and lovastatin were prescribedfor a patient at a dose of 40 mg per day.When the medications were refilled, thelovastatin was inadvertently dispensed inboth vials. The patient proceeded to takedouble the intended dose of lovastatin(and no lisinopril) for more than a monthbefore bone marrow suppression andrhabdomyolysis developed.

In the second case, a vial labeled"lovastatin 10-mg tablets"but containinglisinopril 10 mg was dispensed. Thepatient took the incorrect medication for17 days. Severe orthostatic hypotensiondeveloped, and emergency care wasrequired.

It is believed that these errorsoccurred because the products (whichare from the same manufacturer) werestored close together on pharmacyshelves and had similar-looking packaging.Both patients failed to question anychanges in tablet appearance.

Patients' ability to verify their medicationbased on tablet or capsule appearanceis compromised when pharmaciespurchase the same product from differentmanufacturers, especially on amonth-to-month basis. Under these circumstances,patients become accustomedto changes in product appearance,and thus an opportunity to catchan error is lost.

This pharmacy is now consistently purchasingthe 2 products from different,specific manufacturers. In addition, thepharmacy has separated the 2 drugs inthe storage area by placing them in differentaisles, added warning labels to theshelves, and educated the staff about thepossible mix-ups.

A patient brought the prescriptionseen here into a community pharmacyon a Saturday afternoon. The pharmacistinitially began processing it ashydralazine (due to the spelling and theqid dosing listed on the prescription)but questioned it after checking thepatient's profile and finding no otherantihypertensive listed. When the pharmacistasked the patient why she wentto the doctor, the patient said that shewas being seen for an ear infection, butthe doctor also said that her bloodpressure was a little high.

Due to the potential indicationsdescribed by the patient, the pharmacistwas suspicious as to whether the prescriptionwas for hydralazine or hydroxyzine.The pharmacist called the physician,and the prescription was clarified ashydroxyzine. The physician did not realizethat he had misspelled the drug name. Inthe future, he said that he would write"Atarax"instead.

Luckily, a potential error was avoidedbecause the pharmacist checked theprofile and spoke to the patient. As anadded safety precaution, pharmacistsshould encourage prescribers to includethe brand and the generic name as wellas the purpose on the prescription. 

The reports described here were receivedthrough the USP Medication Errors ReportingProgram, which is presented in cooperationwith the Institute for Safe Medication Practices(ISMP). ISMP is a nonprofit organization whosemission is to understand the causes of medicationerrors and to provide time-critical errorreductionstrategies to the health care community,policy makers, and the public. Throughoutthis series, the underlying system causes ofmedication errors will be presented to helpreaders identify system changes that canstrengthen the safety of their operation.If you have encountered medicationerrors and would like to report them, youmay call ISMP at 800-324-5723 (800-FAILSAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP's Web address is www.ismp.org.

Do Not Be Fooled by Similar Generic Drug Names

For almost a decade, practitionershave been reporting concernsabout the labeling of unit-doserespiratory therapy medications packagedin low-density polyethylene (LDPE)plastic containers. Poor legibility of thelabeling on these products has been afrequent concern reported to the UnitedStates Pharmacopeia-Institute for SafeMedication Practices (USP-ISMP) MedicationErrors Reporting Program (MERP).In fact, the FDA has received more than100 error reports through the MERP andthe FDA MedWatch programs combined.

This problem with legibility is evidentto some practitioners (eg, nurses, respiratorytherapists), as well as to patientsand caregivers who administer thesemedications. Unfortunately, ambulatorycare pharmacists and physicians maynot realize the extent of the problembecause they often do not see the individualunit-dose containers. Many inhalationproducts intended for use by nebulization(eg, albuterol [eg, Proventil], ipratropiumbromide [eg, Atrovent], albuterol-ipratropium combinations [eg,DuoNeb], levalbuterol HCl [Xopenex], cromolynsodium [eg, Intal], budesonide[Pulmicort Respules]) are packaged inLDPE plastic containers. These medicationsgenerally are dispensed in boxesthat contain foil pouches, each holdingmultiple unit-dose containers.

Many of these containers have little differencein shape or color. Even worse, thecontainers have the drug name, concentration,lot number, and expiration dateembossed into the plastic using transparent,raised letters, which are virtuallyimpossible to read (Figure). Some ofthese products also are available in multipledosage strengths, but poorly visiblelabels make it hard to differentiate them.

This embossing method of labeling isused because the FDA no longer permitspaper labels or ink printing on these containers.LDPE is permeable by volatilechemicals (such as those that are used inlabel adhesives, paper, and ink). Contaminationof inhalation solutions canoccur, resulting in the potential forpatient harm. As a matter of fact, FDAstudies have shown that 29 of 37 samplestested positive for volatile chemicals.The presumed sources of thevolatile chemicals were the packagingand labeling materials used, such asadhesives, varnishes, inks, and solvents.

A report from a pharmacist working ina pharmacy that specializes in providingrespiratory medications indicated a highlevel of awareness at her practice site.She explained that typically the pharmacy'spatients receive both albuterol sulfateand ipratropium bromide inhalationsolutions and mix them together in a nebulizerjust prior to administration. Themost common complaint received frompatients is that they cannot differentiateone container of medicine from the other.

This pharmacist receives calls frompatients daily concerning this problem.On several occasions, she has receivedcalls from panicked patients who inadvertentlyused 2 containers of the samemedication instead of mixing one ofeach. She commented on how difficult itis for someone with normal vision toread the embossed labels, let alone anelderly patient with declining vision.

We at ISMP have heard from bothpractitioners and patients who haveused or were considering using markingpens on individual containers to colorcode or mark a letter indicating the drugname or affixing labels to them as ameans to easily identify these medications.Because other substances havebeen shown to permeate through theplastic containers, however, it seemsreasonable that the ink from a markerand volatiles from the label adhesivescould do the same. Therefore, we wouldnot recommend these practices.

On May 5, 2004, the FDA Drug Safetyand Risk Management Advisory Committeemet to discuss how to preventerrors with drug products marketed inunit-dose plastic containers composedof LDPE. Whereas a solution to thelabeling problem was not determined,a number of alternative recommendationswere considered, including thefollowing: (1) embossment using large,easy-to-read fonts; (2) aluminum overwrapfor each individual unit-dose,semipermeable container as protectivesecondary packaging and for labeling;and (3) plastic shrink-wrap over eachpackage to provide background for letteringand bar codes.

The committee noted, however, that,even though inks and glues used for thelatter 2 methods are not in direct contactwith the LDPE packaging, migrationof chemicals in the microenvironment ofthe packaging still might occur. Thus,additional FDA studies to determinewhether such packaging is acceptablealso were suggested—which meansthat additional time is necessary toresolve this problem satisfactorily.

Until the FDA clears up this labelingproblem, consider the following measuresto prevent errors with these products:

&#8266;Avoid adding labels to or writing onunit-dose plastic containers

&#8266;When storing these medications (inphysician offices, pharmacies, patienthomes, etc), ensure that plasticcontainers are stored in their originalboxes, whenever possible. Avoidstoring individual plastic containerstogether in a single location,because many products look alikeand could be mixed together inadvertently.

&#8266;Keep in mind that many of thesemedications are packaged in foilpouches due to light sensitivity.Manufacturers of such products recommendstoring unopened containersin the protective foil pouch untilready to use. Also, most manufacturersrecommend that containersremoved from the foil pouch beused within 1 week.

&#8266;In an effort to keep medications intheir original packaging, pharmacistsshould avoid dispensing partialboxes. If boxes must be "broken up," ensure that plastic containers aredispensed in a clearly labeled packageand that medications packagedin foil pouches are dispensed in anintact foil pouch.

&#8266;Counsel patients regarding the properuse and storage of their medication.Alert them to the potential formisidentification with these products.To reduce this problem, stressthe need to store medications inoriginal, clearly labeled packaging.

&#8266;Be prepared for questions from patientsrelated to the identificationof plastic containers, as well aswhat to do if the wrong medicationor too much of one medication isadministered. Ensure that elderlypatients and those with visual difficultyhave some means of properlyidentifying their respiratory medications,especially if they are usingmore than one. 

The reports described here were receivedthrough the USP Medication Errors ReportingProgram, which is presented incooperation with the Institute for SafeMedication Practices (ISMP). ISMP is a nonprofitorganization whose mission is tounderstand the causes of medication errorsand to provide time-critical error-reductionstrategies to the health care community,policy makers, and the public. Throughoutthis series, the underlying system causes ofmedication errors will be presented to helpreaders identify system changes that canstrengthen the safety of their operation.

If you have encountered medicationerrors and would like to report them,you may call ISMP at 800-324-5723(800-FAILSAFE) or USP at 800-233-7767(800-23-ERROR). ISMP's Web address iswww.ismp.org.

Pharmacy Times and the Institute for SafeMedication Practices (ISMP) would like to makecommunity pharmacy practitioners aware of apublication that is available.

The ISMP Medication Safety Alert! Community/Ambulatory Care Edition is a monthly compilationof medication-related incidents, error-preventionrecommendations, news, and editorial content designedto inform and alert community pharmacypractitioners to potentially hazardous situationsthat may affect patient safety. Individual subscriptionprices are $45 per year for 12 monthlyissues. Discounts are available for organizationswith multiple pharmacy sites. This newsletter isdelivered electronically. For more information, contactISMP at 215-947-7797, or send an e-mailmessage to community@ismp.org.

Illegible Labeling on Inhaled Medications

It is not uncommon for patients toreceive verbal or telephoned instructionsfrom practitioners about howtheir medications should be taken.Unfortunately, as practitioners, weoften do not consider how difficult itmay be for patients to listen to, comprehend,transcribe, and retain importantmedication information.

In a recent report to ISMP, a patientdescribed how her "brain fog" andmisunderstanding of her physician'sinstructions resulted in her takingtwice the intended dose of Levoxyl(levothyroxine) for several weeks.After feeling lethargic and irritable fora few weeks, the woman notified herphysician. The physician ordered laboratorywork to confirm that her symptomswere related to low thyroid levels.During an office visit to review thelab work, the physician explained thather thyroid levels were low and thathe needed to increase her dose of Levoxylto 175 mcg daily. He also mentionedthat, if she was still symptomaticafter a period of time, she coulddouble the dose occasionally to get herlevels back to normal. (He meant thatshe might need to take an additional175 mcg once or twice a week.)

After taking the Levoxyl as prescribed(175 mcg daily) for 1 week, shewas still symptomatic and feeling horrible.She then "remembered" whather physician had said in the officeabout doubling the dose if she still hadsymptoms. She then began taking 2tablets (350 mcg) daily. Several dayslater, she tried to contact her physicianto verify that this was correct butfound out that he was away for 2weeks, so she continued to take 350mcg daily. Her doctor discovered theerror 3 weeks later after she becameincreasingly sick with nausea, vomiting,lightheadedness, and fever.

It is also not unusual for dosage adjustmentswith warfarin to be communicatedverbally to a patient after ahealth care provider has reviewed theoutpatient international normalizedratio levels. A report from a poison controlcenter illustrates how dangerousthis practice can be if dosing informationis misunderstood. A patient whowas taking warfarin required numerousdosage adjustments to maintain a therapeuticlevel. Each time a change wasrequired, the patient was contacted andtold 

of his 5-mg tablets wereneeded for a dose. On one occasion,however, the patient was called andtold to take 7.5 mg daily. He misunderstoodthe directions and took 7.5 of the5-mg tablets (37.5 mg total) for 2 days.Fortunately, the error was discoveredbefore serious harm resulted.

Consider the following when communicatinginformation to patients:

Speak slowly and clearly. Be cognizantof language barriers.

Provide printed information for thepatient to take home, and emphasizeimportant dosing information

Always describe the patient's dose inmetric weight first (ie, mg), and thenprovide instructions regarding thenumber of tablets needed for each doseas well as when to administer each dose

Avoid using the instructions "asdirected" on prescriptions, since patientsmay not recall how to take themedication when they get home

When telephoning patients withinstructions, ask them to:

retrieve a pen and paper beforegiving any dosing changes; 

 writedown the date and the informationas received; and 

 read back thedose and instructions to verifyunderstanding. Advise the patient tokeep the dated instructions with theprescription bottle for referencebecause the directions on the prescriptionbottle may differ from thenew administration directions.

To prevent future confusion, prescribersshould send a prescription tothe patient with the new instructionsor contact the patient's pharmacywith the new instructions and refillinformation. 

The reports described here were receivedthrough the USP Medication Errors ReportingProgram, which is presented in cooperationwith the Institute for Safe Medication Practices(ISMP). ISMP is a nonprofit organizationwhose mission is to understand the causes ofmedication errors and to provide time-criticalerror-reduction strategies to the health carecommunity, policy makers, and the public.Throughout this series, the underlying systemcauses of medication errors will be presentedto help readers identify system changes thatcan strengthen the safety of their operation.

If you have encountered medicationerrors and would like to report them, youmay call ISMP at 800-324-5723 (800-FAILSAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP's Web address is www.ismp.org.

Pharmacy Times and the Institute for Safe MedicationPractices (ISMP) would like to make communitypharmacy practitioners aware of a publicationthat is available.

The ISMP Medication Safety Alert! Community/Ambulatory Care Edition is a monthly compilationof medication-related incidents, error-preventionrecommendations, news, and editorial contentdesigned to inform and alert community pharmacypractitioners to potentially hazardous situationsthat may affect patient safety. Individual subscriptionprices are $45 per year for 12 monthlyissues. Discounts are available for organizationswith multiple pharmacy sites. This newsletter isdelivered electronically. For more information, contactISMP at 215-947-7797, or send an e-mailmessage to community@ismp.org.