Beware! 2020 Top Medication Errors and Hazards

The Institute for Safe Medical Practices (ISMP) recently released its Top 10 Medication Errors and Hazards from 2020, including COVID-19 related risks. Read on for a sneak peek at the list and learn how you can avoid these medication pitfalls. Nurses Headlines Article


Beware! 2020 Top Medication Errors and Hazards

More than 30 years ago, The Institute for Safe Medical Practices (ISMP) initiated a voluntary error reporting program to better understand the common medication errors made by healthcare providers. Today, the ISMP’s Medication Errors Reporting Program (MERP) receives hundreds of error reports every year from practitioners across the nation. The report submissions provide the unique opportunity to learn more about how we can minimize the risk of errors in our own practice.

The Top Ten List

The ISMP recently reviewed the 2020 editions of their newsletter, the ISMP Medication Safety Alert!, to determine what errors should be included in the annual top 10 list.  The following criteria were used to identify and rank errors for the list:

  • Most frequently reported problems
  • Problems causing the most serious consequences
  • Errors and hazards that have been ongoing and
  • Can be avoided or minimized with system or practice changes

You can check out the full top 10 errors and hazards list here.  But for now, let’s take a closer look at the top 5.

Inappropriate use of extended-release opioids to opioid-naive patients

The ISMP, as well as the Food and Drug Administration (FDA), have warned practitioners for decades about the potential harm and death that can occur when prescribing time-released opioids to patients who are not opioid-tolerant.  A big part of the issue..... practitioners often don’t understand a patient’s opioid status when prescribing narcotics.  A patient’s opioid status refers to:

Opioid naive:  patients who are not chronically receiving opioid therapy on a daily basis

Opioid tolerant:  patients who are chronically receiving opioid therapy on a daily basis

For example, fentanyl patches should only be ordered for opioid-tolerant patients for treatment of severe pain that needs long-term and round the clock management.  Prescribing fentanyl to an opioid-naive patient can be dangerous and may lead to an overdose.

To learn more about the safe use of long-acting opioids, read the ISMP’s guideline, Targeted Medication Safety Best Practices for Hospitals.

Not using smart infusion pumps with dose error-reduction systems (DERS) in perioperative settings

“Smart pumps” have become the standard in infusion devices because of their ability to reduce medication errors.  Smart pumps are programmed with dose error reduction software (DERS) which incorporate drug libraries, usual drug concentrations, dosing units and dose limits. And, when an actual/potential dosing error is detected, the smart pump is also programmed with different alerts, such as clinical advisories, hard and soft stops. The technology is valuable in critical care areas, such as perioperative, where high alert medications are used frequently.

Check out this article to learn more about smart infusion pumps with DERS.

Oxytocin Errors

In 2007, the ISMP added IV oxytocin to their list of high alert medications.  Oxytocin is frequently used by perinatal healthcare providers to induce labor.  Common errors associated with IV oxytocin include:

  • Prescribing errors
  • Look-alike vials 
  • Look-alike drug names  (ex. Pitocin and Pitressin)
  • Medication preparation and labeling errors
  • Medication administration errors
  • Problems with hand-off communication

Are you interested in learning more about errors associated with oxytocin? Check out this ISMP report for more information.

Placing infusion pumps outside of COVID-19 patient rooms

It makes sense that some hospitals would place infusion pumps outside the room of COVID-19 patients by using tubing extensions. Hypothetically, this practice conserves PPE, reduces the risk of staff exposure, and allows for staff to hear and respond to pumps more timely.  But, in reality, the length and diameter of the long extension tubing impact priming, flow rates, and administration times.  Here are a few examples of how this practice can be risky:

  • Medication remaining in the extension tubing provides a bolus dose to the patient when the extension tubing is flushed.
  • Alarms that warn of occlusion could be impaired at lower flow rates or become more frequent at higher flow rates.
  • Long extension tubing increases the risk of:
  • Becoming tangled and unintentionally disconnected
  • Increasing the risk of falls
  • Bar scanning of the patient and medication may be more difficult, increasing the risk of error

You can read a special alert released by the Emergency Care Research Institute on the use of large volume infusion pumps during the pandemic here.

COVID-19 Vaccine Errors

The ISMP reviewed vaccination errors that were voluntarily reported since mid-December 2020.  Reported errors included:

  • Multiple errors made, specifically with the Pfizer-BioNTech vaccine, when the person administering the vaccine did not use enough diluent, causing an overdose.
  • Unclear labeling led to patients receiving IM injections of a monoclonal antibody instead of the Moderna vaccine.
  • Vaccines were unnecessarily wasted because of inadequate scheduling processes or “no-shows”.
  • Vaccines were administered to individuals younger than the recommended age.
  • A small number of allergic reactions were also reported.

Read the ISMP’s full COVID-19 vaccination error report with recommendations for prevention here.

Interested in Learning More?

Be sure to check out the ISMP’s website for urgent medication safety alerts about serious potential errors. You can access the Medication Safety Alert page here.

Let’s Hear From You

Have you had a “near miss” with any of the above errors? Also, would love to hear about any medication hazards you’ve experienced related to the pandemic.


J. Adderton MSN has over 25 years of experience in clinical leadership, staff development, project management and nursing education.

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Specializes in ICU.

Great article, thanks J!!

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