ISMP Identifies Errors with Extended-Release Opioids, Infusion Pumps as among Top Medication Safety Issues in 2020

Top 10 List Published in ISMP Newsletter

February 2, 2021

Horsham, PA—ISMP has released a list of the top 10 most persistent medication errors and hazards covered in its acute care newsletter in 2020. The list focuses on safety problems that are frequently reported, caused serious harm to patients, and could be avoided or minimized with system and practice changes attainable by all healthcare providers. ISMP believes that these issues merit attention and priority if action has not already been taken to mitigate risk, and the newsletter article provides specific prevention recommendations.

Two of the top 10 categories identified are closely associated with the pandemic--errors with COVID-19 vaccines and risks associated with positioning infusion pumps outside COVID-19 patients’ rooms. However, ISMP President Michael Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, emphasizes that all of the issues identified merit increased attention and priority when possible. “We know that the pandemic has created an incredibly challenging year for healthcare providers,” says Cohen. “Obviously, organizations have to prioritize dealing with COVID-19 surges and care, but we hope that they can keep these important medication safety problems on their radar and address them once they are not fully consumed by the pandemic.”

ISMP hopes that the following hazards and errors become an essential part of healthcare organizations’ strategic medication safety improvement plans this year:

ISMP Top 10 Medication Errors and Hazards List for 2020

  • Prescribing, dispensing, and administering extended-release opioids to opioid-naïve patients. ISMP continues to receive reports of inappropriate prescribing of these medications, including fentanyl transdermal patches, resulting in serious harm and death. A 2020 ISMP survey of best practices associated with avoiding this risk showed low compliance by healthcare organizations.
  • Not using smart infusion pumps with dose error-reduction systems (DERS) in perioperative settings. ISMP’s updated guidelines recommend use of pumps with DERS throughout healthcare organizations, for all infusions (including hydrating solutions) and bolus/loading doses. However, use in the perioperative setting is limited due to barriers and challenges.
  • Errors with oxytocin. In 2020, ISMP conducted an analysis of oxytocin errors, many of which caused hyperstimilation of the uterus, which can result in fetal distress, uterine rupture, or an emergency cesarean section. Many of the reported errors were associated with look-alike vials and label confusion, inadequate labeling of nurse-prepared oxytocin infusions, or mix-ups between an oxytocin infusion and either a hydrating fluid or magnesium infusion.
  • Hazards associated with positioning infusion pumps outside of COVID-19 patients’ rooms. Some hospitals are placing infusion pumps in hallways to conserve personal protective equipment, reduce staff exposure, and enhance ability to respond to alarms quickly. Unfortunately, the use of extension tubing sets can impact volume of fluid needed for priming, flow rates, and time medications/solutions take to reach a patient. Long tubing may also pose a tripping hazard, and barcode scanning at bedside may be prevented as well as certain components of independent double checks.
  • Errors with the COVID-19 vaccines. ISMP’s findings from analyzing recent flu vaccine errors can be used to prevent errors during COVID-19 vaccination campaigns. Common contributing factors associated with flu vaccines that could also apply for COVID-19 vaccinations include look-alike vaccine names, labels and packaging; unsegregated refrigerator/freezer storage; mixing/dilution errors; patient communication barriers; not checking/documenting administration in the immunization information system; temperature excursions; and the inability to use technologies such as barcode scanning.
  • Use of the retrospective, proxy “syringe pull-back” method of verification during pharmacy sterile compounding. In ISMP’s 2020 survey on pharmacy sterile compounding systems and practices, only half of respondents reported that it is always easy to verify with certainty which drugs, diluents, and volumes were used. Respondents with the lowest confidence were using outdated, post-production “syringe pull-back” method. ISMP has received multiple reports of harmful or fatal errors, mostly preparing the wrong concentration/strength or using wrong product/diluent, due to the use of this method.
  • Combining or manipulating commercially available sterile products outside the pharmacy. ISMP’s 2020 survey on admixture outside the pharmacy showed that this error-prone practice happens often during emergency situations, mostly without formal training. Nearly one-third of respondents were aware of associated errors in the past year, particularly mixing errors (e.g., wrong drug, dose, concentration, diluent, diluent volume).
  • Medication loss in the tubing when administering small-volume infusions via a primary administration set. When primary administration tubing sets are used to administer small-volume intermittent IV infusions, patients may not receive their full dose of medication. In one health system, about 360,000 small-volume infusions annually were administered to patients at lower doses than prescribed, which could have a clinical impact on patient outcomes.
  • Wrong route (intraspinal injection) errors with tranexamic acid. ISMP continues to receive reports involving accidental intraspinal injection of tranexamic acid instead of a local anesthetic intended for epidural or spinal anesthesia. Bupivacaine, ropivacaine, and tranexamic acid are sometimes packaged in vials with the same blue color cap, which can lead to mix-ups. This is the only error type repeated from ISMP’s top ten list for 2019, and it is the only error type that led to ISMP issuing a warning through the National Alert Network in 2020.
  • Use of error-prone abbreviations, symbols, or dose designations. Although abbreviations, symbols, and dose designations can be a time saver, they can be misread or misinterpreted. ISMP is currently reviewing and updating its list of error-prone abbreviations, symbols, and dose designations.

For a copy of the full ISMP newsletter article, visit: Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020 | Institute For Safe Medication Practices ( Access may require free registration.

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Visit and follow @ismp_org to learn more.

For more information, contact:
Renee Brehio
ISMP Public and Media Relations