nurse mar06-v5.qxd - Institute For Safe Medication Practices

ISMP Medication Safety Alert!®
Educating the healthcare community about safe medication practices
Patient's watchful eye leads to pump tampering
A hospitalized patient with chronic
pain was able to increase the rate of
his HYDROmorphone (D
infusion and administer bolus doses
to himself. The patient had been
receiving HYDROmorphone via a
CADD-Prizm VIP pump (from
Smiths Medical) at home before he
was admitted to the hospital late one
evening. The admitting physician
prescribed the same dose of
HYDROmorphone as the patient
had been receiving at home, and
allowed the patient to use his pump
from home while in the hospital.
given himself frequent boluses (not
prescribed). The patient's home
CADD pump was replaced with a
hospital CADD pump (different
model) and secured with a lock to
prevent further tampering.
Obviously, the patient knew how to
manipulate the pump. He had
obtained and used the lock level
code to alter the pump settings, and
the clinician code to give himself
bolus doses. But how did he gain this
At the request of FDA and
others to provide readily
The hospital-based pain
accessible information,
service team had been
learned the
the pump's user manual
following the care of the
codes by observpatient at home. But the
ing practitioners is available on the manufacturer's website. This
team was not notified of
while programprovides
patients with
his admission until the
ming the
about how to
following morning when a
program the pump. Howresident called them to quesever, the codes are not in the
tion why the patient's
web publications; they appear only
HYDROmorphone was infusing at a
in the hardcopy of the user manual
different rate than prescribed. The
that the facility receives. Thus, the
team member told the resident that
patient likely obtained the lock level
they had not changed the dose and
and clinician codes for the pump he
would be unable to see the patient
used at home by observing practitionuntil later in the day because of a
ers programming the pump in the
busy clinic schedule. The resident
hospital. A much less remote possidid not investigate the change in the
bility is that the codes, which are the
infusion rate any further.
same for this pump throughout the
US when shipped from the manufacEighteen hours elapsed before the
turer, had been communicated via
pain service physician was able to
visit the patient. Nursing documenta- the Internet or email by others.
tion regarding how much medication
While there may be no foolproof way
should have infused differed signifito prevent patient tampering with
cantly from the pump's electronic
pumps, see check out! for several
patient history log. When comparing
the two, the physician quickly discov- things that healthcare providers can
ered that the patient had somehow
do to reduce the risk of tampering or
manipulated the infusion rate and
to detect it quickly if it occurs.
Newsletter Funding 2006
We are pleased to announce that McKesson will continue to provide ISMP with an educational grant to sponsor free distribution of Nurse Advise-ERR™ for the remaining
6 months of 2006. Join us in thanking them by emailing:
Supported by an educational grant from McKesson
March 2006
Volume 4 Issue 3
check out! To reduce the risk of patient tampering
with pumps that deliver opioids, or to
detect such tampering quickly:
Use hospital pumps. To enhance
security, use only hospital-approved
pumps to administer opioids to hospitalized patients. Do not allow patients
to use their pumps from home.
Shielding and scrolling. When
programming a pump, always block
the patient's (and visitor's) view and
use the scroll up or down keys if available to prevent patients from counting
how many times the keys are pressed.
Checks and balances. Require
the use of carefully designed flow
sheets during opioid infusions to track
cumulative doses over time (4-hour
increments for inpatients) while referencing the pump's patient history log
for comparison to the prescribed dose.
Investigate. Consider the possibility
of patient tampering (or an error) if the
amount (dose and volume) administered does not match the prescribed
dose, or if the patient's sedation level,
respiratory status, or behavior appears
different than expected.
Patient education. Be sure
patients understand how to report
increasing or unrelieved pain. Some
patients who experience difficulties
with pain management are driven to
extremes for relief. Provide assurance
that you will contact their physician
about unrelieved pain, who will subsequently assess and manage the
patient’s pain more effectively.
Staff education. When educating
staff and other caregivers to use
pumps, stress ways to minimize the
risk of patients and visitors learning the
programming codes.
continued on page 2
Page 2
March 2006
Another risk of IV misconnections and free-flow
KCI is a wound healing system that
facilitates automated delivery of topical solutions (e.g., Dakin's solution,
silver nitrate solution, SULFAMY LON [mafenide acetate]) to wound
sites. While very different from an
infusion pump, the device is programmed to deliver irrigation fluid at
a desired rate; but it lacks protection
from gravity free-flow if the tubing is
removed. Unfortunately, the V.A.C.
is designed to accommodate IV tubing to deliver the topical solution.
Thus, a nurse could inadvertently
attach the "IV" tubing intended for
the V.A.C. to an IV port.
Previously reported misconnections
of seemingly dissimilar tubing (e.g.,
blood pressure, oxygen, and air supply tubing) to IV ports should serve
as a reminder that such an event is
possible. In fact, there are a few
additional conditions that heighten
the risk of connecting the V.A.C.
tubing to an IV line. Most V.A.C.
topical solutions are prepared in "IV"
bags, so both the bags and tubing
look like those used to deliver IV
solutions. The V.A.C. provides a
detachable "IV" pole (as described in
product literature) upon which to
hang the solution. Finally, the V.A.C.
is indicated for recalcitrant wounds,
so it's used infrequently. Thus, staff
may be unfamiliar with the device
and unaware of the risk of misconnections. Furthermore, there will be
no protection from gravity free-flow
if the tubing is erroneously attached
to an IV site and later removed from
the V.A.C. Photos of the V.A.C.
Instill System are available online at:
The reporting nurse has asked the
manufacturer, KCI, to develop specific tubing that connects only to
their equipment. Meanwhile, misconnections are less likely if you label
all lines; physically trace all lines from
the source solution to the port
of insertion; and require an independent double check before initial
use of the device, or when replacing
bags of solutions. Additionally, ask
pharmacy to apply an easily visible
“For irrigation use only” label and a
brightly colored overwrap before dispensing. Also consider asking pharmacy to prepare topical solutions in a
container dissimilar to typical IV
solutions, such as a 500 mL bottle.
Volume 4 Issue 3
continued from page 1
check out!
Check security features. Check
all pumps used for opioid infusions
(and new pumps considered for
purchase) to ensure that the locking
mechanism for the compartment that
holds the medication is functional and
reliable. If it is not, request a replacement pump immediately. (Patients
and visitors have used pens, paper
clips, or other objects to push the
syringe plunger, syringes with long
needles to aspirate the medication,
or moderate pressure to open the
locked compartment.)
Change codes. Some pumps offer
biomedical engineering staff the capability of changing the lock level and
clinician codes. Consider requesting a
temporary code change for patients at
risk for tampering with the pumps as
long as the new codes can be securely
communicated to all practitioners who
need the information.
Notify the pain service. If your
facility offers a pain service, notify the
team immediately upon admission of a
patient with chronic pain, especially if
the patient has been receiving opioids
in the home setting.
Special Announcement
ISMP Teleconferences. Please join us for a two-part teleconference series
covering Just Culture. Part I, Just Culture-An Emerging Safety-Centered
Accountability Model, will be held on March 30, 2006. Part II, Journey
Toward a Just Culture-A Statewide Initiative, will be held on April 19, 2006.
Both programs will be held from 1:30 to 3:00 p.m. (ET). In Part I, David Marx, JD,
will describe the basic tenets of a Just Culture, a groundbreaking way to promote
an open and fair healthcare environment, especially as it relates to error investigation. (This is a repeat of our October 2005 teleconference.) Speakers for Part II
will chronicle the statewide effort among healthcare providers and state licensing
boards to adopt a Just Culture throughout the healthcare industry in Minnesota.
Shirley Brekken, from the Minnesota State Board of Nursing, Tania Daniels,
from the Minnesota Hospital Association, and Alison Page, from Fairview Health
Services will be the featured speakers, each bringing a unique point-of-view to the
experience. For details and to register, visit:
Mosby’s Nursing PDQ for Medication
Safety prepared by ISMP. This pocketsized reference has quick facts and errorreduction strategies for high-alert medications, look-alike drugs,
high-risk procedures, and
error-prone abbreviations. The guide also
offers information and
tips on assessing risk,
error reduction, error
reporting, and more. For
information and to order, please visit:
ISMP Medication Safety Alert! Nurse Advise-ERR (ISSN 1550-6304) ©2006 Institute for Safe Medication Practices (ISMP). Permission is granted to
subscribers to reproduce material for internal newsletters or communications. Other reproduction is prohibited without written permission. Unless noted,
published errors were received through the USP-ISMP Medication Errors Reporting Program. Editors: Judy Smetzer, RN, BSN; Nancy Tuohy, RN, MSN;
Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Tel. 215-947-7797;
Fax 215-914-1492; EMAIL: Report medication errors to ISMP at 800-FAIL-SAF(E).
ISMP seeks an RN Medication Safety Specialist for publications. Details at: