5 COVID-19 related medication errors reported to ISMP

The Institute for Safe Medication Practices, a nonprofit watchdog for prescription drug safety, on May 14 published a list of medication errors reported by hospitals related to treating COVID-19 patients.

Five medication errors:

  1. Hard-to-read remdesivir labeling
    Remdesivir vials aren't clearly labeled, and the information on the label is crowded in a small font, hospitals told the institute. The label doesn't include the total dose contained in the vial, so some hospitals have had issues administering the correct doses of remdesivir to patients. The recommended dosage is an initial 200mg of remdesivir, followed by doses of 100mg.

  2. Lack of staff training in using medicine bar codes
    Bar code medication administration is a common practice in hospitals used to reduce medication errors. Drugs are labeled with electronic barcodes that providers can scan to ensure that they have the correct drug and dosage for a specific patient. However, because some hospitals have had to move nurses to different units than ones they are used to working in, some nurses haven't been trained in the use of bar codes, leading to more medication errors.

  3. Inability to weigh patients, assure correct dosage
    Without being able to weigh patients during telehealth visits, providers have sometimes been unable to get reliable numbers from patients. This can lead to incorrect dosages of weight-based drugs. 

  4. Automated cabinets dispensing wrong drug
    Some drugs are kept in automated dispensing cabinets in hospitals. If a provider only types in the first few letters of the drug they are looking for, this can sometimes lead to them selecting the wrong drug. One hospital reported such an error that occurred when a nurse accidentally selected and gave to a COVID-19 patient a high blood pressure drug instead of the sedative the physician ordered because both drugs started with the same few letters.

  5. Missed doses linked to rationing of personal protective equipment
    Some hospitals have reported an increased number of missed doses because providers are hesitant to enter patients' rooms multiple times to administer drugs for fear of running out of personal protective equipment. Communication errors between nurses and respiratory therapists have also caused missed doses of drugs in COVID-19 patients, hospitals said.

More articles on pharmacy:
32 of 40 drugs deemed critical for COVID-19 in short supply
Gilead strikes deal to manufacture remdesivir for 127 countries
How Civica Rx has responded to drug shortages caused by COVID-19

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