Reinforce Strategies to Prevent Serious Med Errors

You’ll have an opportunity to reinforce safety strategies for some top causes of harmful medication errors.

Help your team implement ISMP’s error-reduction strategies for tranexamic acid...vaccines...and transitions of care.

Prevent wrong-route errors with tranexamic acid. Look-alike tranexamic acid vial caps make it easily mistaken for local anesthetics...which are sometimes given intrathecally.

Accidental intrathecal administration of tranexamic acid can cause seizures...permanent neurological damage...and about 50% of patients die.

Use premixed 1 g IV bags whenever possible...and keep tranexamic acid vials OUT of anesthesia trays. If premixes are unavailable, manually compound tranexamic acid drips...to avoid mix-ups in procedural areas.

Store vials horizontally so labels can be seen. Consider adding “Contains tranexamic acid” labels to vial caps for another layer of protection...since barcode scanning doesn’t always happen in these areas.

Reduce errors with vaccines. Require brand AND generic names in vaccine orders...and utilize standard order sets. Take extra steps to help avoid confusion with abbreviations.

For example, Tdap or DTaP is used for pertussis, diphtheria, and tetanus. But Tdap is for older kids and adults...DTaP is for children younger than 7 years.

Use auxiliary labels to help differentiate...store similar vaccines separately...and always use barcode scanning.

Double-check patients’ immunization status using your state’s vaccine registry. Update the EHR if needed...and watch for allergies to latex or inactive ingredients.

Make sure vaccines are delivered stat...and provide nurses with the vaccine NDC, lot number, and expiration date before administration.

Suggest that your hospital stock prefilled syringes when possible. If vaccines must be prepped, do this immediately prior to administration. Store 2-component vaccines together to avoid diluent mix-ups.

Limit med mishaps during transitions of care. Assign dedicated staff to obtain an accurate med list on admission. Include Rxs...OTCs...supplements...and allergies.

Ensure meds get discontinued appropriately with each level of care change...such as antipsychotics for delirium once patients leave the ICU.

Also help the team restart meds when appropriate...such as anticoagulants that were held while ruling out a bleed.

Use our Transitions of Care Checklist for more guidance at admission, transfer between units, and discharge.

• Checklist: Transitions of Care Checklist