3.

3 Tall Man Lettering

Tall Man lettering is a technique that uses a combination of lower- and upper-case letters to
highlight the differences between look-alike drug names, helping to make them more easily
distinguishable.4
Some examples are:

 amIODAROne / amLODIPIne
 CARBAMazepine / carbIMAZOLe
 cLOMIPRAMIne / cHLORPROMAZIne
 fluOXETine / fluVOXAMine
Tall Man lettering helps to alert health care professionals to the risk of confusing a particular
medicine name and helps to ensure the intended drug is dispensed or administered to the
patient. It is designed for use in electronic prescribing systems and on medication storage
shelves (not for handwritten prescriptions). Its use is likely to become more widespread as
electronic systems are further developed and implemented in hospitals across Australia.

5.5 Barcode scanning to avoid product selection errors

Barcode scanning technology can help to reduce product selection errors.6 It is used in
community and hospital pharmacies across Australia. It involves the pharmacist scanning both
the product and the dispensing label barcode to verify that the correct product and strength has
been selected for supply. Any discrepancy results in a warning flag to alert the pharmacist. The
technology may eventually be extended to the ward environment where doctors and nurses
could use it when administering medicines.

4.6 Intravenous medications given orally: Some precautions

In certain situations, the only means of administering an intravenous product is via the
oral/enteral route. You should always check with a clinical pharmacist or accepted
reference source before doing this.
Although safe to give orally, intravenous products are not designed to disguise the taste or smell
of the drug so can be unpalatable for patients.
This special situation requires extra care to ensure that even though you are using an IV
formulation you do not give the dose intravenously. Oral doses are not always the same as
intravenous doses — inadvertent intravenous administration could result in an overdose. An oral
dispenser should be used to administer the product.

Sometimes when IV preparations are used orally, more than one dose can be obtained from a
vial or ampoule and so the pharmacy may prepare a bottle of oral liquid from an IV product. Once
opened, the IV product becomes unsterile and must not be used for IV administration. Opened or
repackaged products must be clearly labelled to ensure they are used for oral administration only
and not inadvertently given intravenously.

Remember, it is sometimes OK to give IV formulations orally, but medications designed

for oral use should NEVER be given intravenously.
 5.0 Intravenous medications given intrathecally

A number of medications, such as opioids, corticosteroids and anticancer agents are routinely
injected intrathecally (into the cerebrospinal fluid) for therapeutic benefit. However, certain
medications and products can be dangerous if administered via this route.
Most medications have had little or no testing for safety when administered intrathecally, and as
such, the consequences of administering via this route may be unknown. It is widely accepted
that products containing preservatives should not be administered intrathecally, as there have
been reports of adverse effects4.

7.0 Intravenous and epidural mix-ups

It is common, especially post-surgery, for patients to have both intravenous and epidural lines in
situ.
Errors occur when a medication is inadvertently injected into the wrong line or when syringes
intended for IV and epidural use are mixed up.
Reported effects of inadvertent injection of an intravenous drug into the epidural space range
from pain and sedation to permanent quadriplegia and death.11
The opposite is also possible, whereby a drug intended for epidural use is injected into an IV
line.12 Depending on the drug involved these errors can also have devastating outcomes.
Long-acting local anaesthetic agents, such as bupivacaine, are commonly administered by the
epidural route for obstetric and post-surgical pain. Inadvertent IV administration of local
anaesthetics can result in serious cardiovascular effects including:

 life-threatening atrioventricular block,

 ventricular arrhythmias, and
 depressed cardiac contractility.

9.0 Errors with ear and eye preparations

Wrong route errors involving eye and ear drops have occurred. It is important to remember that
ear drops should NEVER go in the eye (although some eye products can be used safely in the
ear).
Because eye tissue is much more sensitive than ear tissue, eye drops are specifically formulated
to be gentle to the eyes and are sterile to avoid infection. Ear drops are not designed in this way.
Many ear drops contain ingredients which can irritate the eyes, and because they are not always
sterile, may introduce infection to the eyes.
For example, some ear drops contain peroxide, which if instilled in the eyes will cause pain,
redness, swelling and blurred vision.

With oral dosing usually only part of the dose reaches the bloodstream and has an effect. Some
of the drug may be destroyed by enzymes in the gastro-intestinal tract, some will not pass
through the gut wall into the blood and some may be metabolised in the liver before it reaches
the general circulation (known as “first pass metabolism”). However, with IV dosing the entire
dose is immediately available in the bloodstream so the entire dose has an effect. The amount of
drug reaching the general circulation is known as the bioavailability. Drugs with a low oral
bioavailability include beta-blockers and some opioids. The IV doses of these drugs are much
more potent than oral doses of the same drug.
Select the abbreviations that are used to indicate that the product is a controlled-release
formulation.

Your answer is incorrect.

You have either not selected all the correct options, and/or you have selected some incorrect
options.
MR
Modified Release (used for gliclazide eg, Diamicron MR).
ED
Every Day (used for oral contraceptives which are taken on 'every day' of the cycle eg,
Microgynon ED).
DS
Double Strength (used for Bactrim DS).
LA
Long Acting (used for methylphenidate eg, Ritalin LA).
XL
Extended Release (used for nifedipine eg, Adefin XL, metoprolol succinate eg, Toprol XL).
CR
Controlled-Release (used for carbamazepine eg, Tegretol CR).
EC
Enteric Coated. The enteric coating on a tablet protects the drug from the stomach acid. It does
not make the formulation controlled-release. This is discussed in more detail later in the
module.
XR
Extended Release (used for nifedipine eg, Addos XR, metformin eg, Diaformin XR and Diabex
XR, venlafaxine eg, Efexor XR, quetiapine eg, Seroquel XR).
CD
Controlled Delivery (used for diltiazem eg, Cardizem CD and Vasocardol CD).
ER
Extended Release (used for felodipine eg, Plendil ER and Felodur ER).

4.2 Can controlled-release tablets be halved?

You are asked for your advice on the following prescription.

The patient can swallow tablets.

The nurse has found some isosorbide mononitrate SR 60 mg (Imdur) tablets in the patient's
bedside locker.

In this case, because the tablets are scored, ½ x 60 mg tablet can safely be given. Controlled-
release tablets that are scored may be broken cleanly in half without affecting the product's
release characteristics. However, they should still NOT be crushed or chewed.
Controlled-release tablets that are not scored must not be broken. For example, nifedipine SR 60
mg tablets should not be halved to administer a 30 mg dose.
These capsules may be opened and the granules sprinkled into a small amount of food or liquid,
but the granules themselves must remain intact. Crushing or chewing the granules will destroy
the controlled-release mechanism and cause rapid release of the medication into the
bloodstream. If sprinkling into food or drink, the patient should be advised not to chew the
granules. Remember that the patient must consume the entire volume of food or drink to ensure
they receive the full dose.
Controlled-release granules such as these can also be administered down wide-bore feeding
tubes. The tube should be flushed well to ensure that the granules don't block the tube.
Always check the product information or ask a pharmacist if unsure about how to administer
controlled-release capsules and granules.

7.1 Transdermal patches

A patient was transferred from a residential aged care centre with a buprenorphine patch in
place. The buprenorphine patch was ceased on the medication chart by a medical officer and
controlled-release oxycodone initiated in its place. Three days later the buprenorphine patch was
found still affixed to the patient.
There have been numerous cases in which patches that should have been removed have been
found still in place on hospitalised patients. It is important to ensure that the patch is removed if
the medication order is ceased. If a patch is removed by medical staff this should be
communicated to nursing staff so that the patient can be monitored accordingly.
It is also essential to ensure that the previous patch is removed before applying a new patch. The
application and removal of a patch should be documented in the medical notes. The time of
application should also be written clearly on the patch itself using a black pen.

6.6 Structured communication tools

SBAR
SBAR is a structured method of communicating critical information that has 4 steps.
Situation
Briefly describe the current situation
Give a clear, succinct overview of pertinent issues
Background
Briefly state the pertinent history
What got us to this point?
Assessment
Summarise the facts and give your best assessment
What is going on? Use your best judgement
Recommendation
What actions are you asking for?
What do you want to happen next?

View a larger version of this poster here.

6.6 Structured communication tools

ISBAR
Introduction
Identify yourself and give a reason for calling
Situation
Give the patient's age and gender
What is the patient's status now?
Background
Give the relevant details such as presenting problems and clinical history
Assessment
Put it all together (their current condition, risks and needs.) What is your assessment?
Recommendation
Be clear about what you are requesting
When should it happen?

6.6 Structured communication tools

ISOBAR
Introduction
Introduce yourself and your patient
Situation
Why are you calling? Briefly state the problem
Observation
Recent vital signs and clinical assessment
Background
Pertinent information related to the patient
Assessment
What do you want?
Given the situation what needs to happen?
Readback
Confirm shared understanding
Who is doing what and by when?

7.3 The Graded Assertiveness technique

There are a number of methods that are used in healthcare to help professionals overcome
authority gradients. One such method is known as the Graded Assertiveness technique.12 It
has been adapted from aviation, an industry where a strong culture of “speaking up for safety”
exists.
The Graded Assertiveness technique focuses on WHAT is wrong rather than WHO is wrong.
It is based on the PACE acronym:

Probe for a better understanding of the situation

Alert to the anomalies in the situation

Challenge suitability of the present situation

Emergency action to reduce the risks

Identify the error

Your answer is correct.

A dose error has occurred.

The prescriber has calculated the dose based on the patient's actual body weight (5 mg/kg x 140
kg = 700 mg). Therapeutic Guidelines version 16 recommends actual body weight is used for
gentamicin dose calculations in people who are underweight, healthy weight or overweight,
and adjusted body weight (adjusted body weight = Ideal body Weight (IBW) + 0.4 x (actual
body weight - IBW) : see Box 2.46) is used for people who are obese (BMI 30 to 34.9kg/m2). If
actual or adjusted body weight is greater than 100 kg, a weight of 100 kg should be used to
calculate the dose. Calculating initial gentamicin doses is complicated in patients with altered
pharmacokinetics so prescribers should refer to dosing guidelines (see Table 2.72 and 2.73).
Therapeutic Guidelines recommends seeking expert advice for obese adults with a body mass
index (BMI) of 35 kg/m2 or more – this would include Mr F who has a BMI of 49.6 kg/m2.
In general, when selecting an appropriate dose of a medication, the patient's individual
parameters should be taken into account. In obese patients doses may need to be based on
ideal body weight rather than actual body weight, or in the case of aminoglycosides, adjusted
body weight depending on the BMI category, or there may be a maximum recommended dose.
Dosing guidelines should always be followed carefully to ensure that a safe and effective dose is
given.
This error must be acted upon immediately to ensure that no further incorrect doses are given
and that the patient is monitored appropriately to minimise any adverse effects.

All of these are unacceptable.

G5 – this is an unacceptable abbreviation. It could have a number of interpretations.
KCl – this chemical symbol can be misinterpreted especially if not written clearly. The name of
the intended product should be written in full.
40 – this is intended to be the quantity of potassium to be given, but is unclear as the units are
missing.
 8° – the degree sign (intended to mean “over x hours”) is an error-prone symbol, as the symbol
can be read as a zero and interpreted as part of the dose or rate. The rate should be prescribed
as volume/time (for example mL/hour).

16.0 Conclusion
Congratulations
You have completed Case Study 1 - Mr F.
Write down or screenshot your unique completion code before exiting: msv3cs13353111.
You will need to provide this code to customer service if your completion does not save.
You may now like to complete Case Study 2 - Mr L.
To ensure your completion is recorded properly:

1. Click on the Exit button to close this module and return to the course page.

2. Print or download your certificate of completion from the course page.

6.0 Best possible medication history

An accurate medication history is the baseline from which drug treatment will be continued at the
time of admission, therapeutic interventions will be made, and self caring will be continued after
discharge.1
To obtain the best possible medication history you should, where possible, use more than
one source of information. One of these sources should always be structured interview with the
patient or their carer. In this case we used:

1. an interview with the patient's carer (his son)

2. the patient's own medication list

3. the patient's own medications

It is important to compare the information provided by the different sources and seek clarification
on any differences. The medication history should be documented either on the Medication
Management Plan form (if used in your hospital) or in the medical record.

Well done. It is called 'open disclosure' because when things go wrong, the patient and their
family should be provided with information about what happened in an open and honest manner.
They should also be informed of the potential consequences and the steps being taken to
manage the event and prevent recurrence.
Click here to review the Australian Commission on Safety and Quality in Health Care (ACSQHC)
Open Disclosure Standard.

A senior staff member, trained in the process of open disclosure, should discuss the incident with
the patient.
The person identifying the error should immediately discuss the issue with senior staff
members involved in the patient's care.
The person who made the error should be informed of the error (if not already aware). They
may be able to identify factors that contributed to the error. This information could be used to
help prevent similar errors from occurring again. The open disclosure process also involves
providing support and advice to the staff members involved in the incident without apportioning
blame.

15.0 Conclusion
Congratulations
You have completed Case Study 2 - Mr L.
Write down or screenshot your unique completion code before exiting: msv3cs23453811.
You will need to provide this code to customer service if your completion does not save.
To ensure your completion is recorded properly:

1. Click on the Exit button to close this module and return to the course page.

2. Print or download your certificate of completion from the course page.