Hospital Pharmacy - April 2012 - (Page 260)

Hosp Pharm 2012;47(4):260–263 2012 Ó Thomas Land Publishers, Inc. www.thomasland.com doi: 10.1310/hpj4704-260 ISMP Medication Error Report Analysis Error Prevention Strategies for Strong Iodine Solution Do Not Use an Insulin Pen for Multiple Patients Michael R. Cohen, RPh, MS, ScD,p and Judy L. Smetzer, RN, BSN† These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers’ names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters’ wishes as to the level of detail included in publications. ERROR PREVENTION STRATEGIES FOR STRONG IODINE SOLUTION Our sister organization in Canada, ISMP Canada, recently published a safety bulletin on oral dosing errors associated with Lugol’s solution (potassium iodide and iodine), also referred to as strong iodine solution.1 The organization had recently received 3 reports involving incorrect oral dosing of Lugol’s solution. A quick search of the Quantros MedMarx and ISMP National Medication Errors Reporting Program (ISMP MERP) databases showed that a dozen oral dosing errors have been reported in the United States in the past 6 years. Most dosing errors have involved prescribing, dispensing, or administering milliliter doses of Lugol’s solution when just a few drops were indicated. One contributing factor may be that oral liquid medications for adults and young children are typically dosed in milliliters, while drops are typically reserved for infants. Thus, an adult dose expressed in drops is uncommon. Another factor is that the product is used relatively infrequently and may be prescribed during an emergency. Thus, unfamiliarity with the drug has been linked to many dosing errors. Lugol’s solution contains 100 mg/mL of potassium iodide and 50 mg/mL of iodine. Given orally, the product (a) reduces thyroid vascularity (used to reduce blood loss during thyroid surgery); (b) temporarily inhibits thyroid hormone synthesis and secretion (used in treating thyrotoxic crisis and in reducing the risk of thyroid storm post thyroid surgery); and (c) blocks thyroidal uptake of radioactive isotopes, thereby reducing the risk of thyroid cancer (used in a radiation emergency or therapeutic/ diagnostic exposure of radioactive iodine). Lugol’s solution is also approved for use as a topical antiseptic. Of the 3 errors reported to ISMP Canada, one was described in detail in the bulletin.1 This event involved an adult patient with Grave’s disease who was admitted to the hospital with thyroid storm. The physician prescribed 4 drops of Lugol’s solution to be given orally every 8 hours. The intended dose of 4 drops would require approximately 0.2 mL of Lugol’s solution. But this patient was accidentally given an entire 100 mL container of the solution in a single dose, which amounted to a total of 5 g of free iodine. Acute toxicity of Lugol’s solution is related to its iodine content,1 although the high potassium concentration *President, Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044; phone: 215-947-7797; fax: 215-914-1492; e-mail: mcohen@ismp.org; Web site: www.ismp.org. †Vice President, Institute for Safe Medication Practices, Horsham, Pennsylvania. 260 Volume 47, April 2012 http://www.thomasland.com http://www.ismp.org http://www.ismp.org

Table of Contents for the Digital Edition of Hospital Pharmacy - April 2012

Hospital Pharmacy - April 2012
Editorial
ISMP Medication Error Report Analysis
ISMP Adverse Drug Reactions
Cancer Chemotherapy Update
Off-Label Drug Uses
Original Article
Symptomatic Bradycardia, Syncope, and Prolonged Qtc Interval Associated With Dronedarone Therapy
Extended Stability of Magnesium Sulfate Infusions Prepared in Polyolefin Bags
Formulary Drug Reviews
Continuing Education Case Study Quiz (0.15 CEU)
Current FDA-Related Drug Information
Pharmacy Automation and Technology
Director’s Forum
Hospital Pharmacy Pulse
Index to Advertisers

Hospital Pharmacy - April 2012

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