Team approach needed to reduce nebulizer errors

Omission of nebulized medications is most frequent error, says ISMP report

In a recent report on common errors with nebulized medications, the Institute of Safe Medication Practices (ISMP) recommends forming an interdisciplinary team of physicians, pharmacists, nurses, and respiratory therapy staff to implement safe practice steps to reduce these errors.

Common nebulizer errors cited by ISMP in the report included omissions of medications when staff were unaware of orders or did not communicate with one another, mix-ups of look-alike nebulizer vials or other look-alike containers (e.g., diluents), automated dispensing cabinet errors resulting from staff overrides, failure to use barcode scanning systems, equipment errors, and administration via the wrong route.

The most frequent error cited by ISMP, accounting for more than half of the error reports received during 2016 and 2017, was omission of nebulized medications. The respiratory staff was either unavailable, unaware of the order, or assumed the patient did not need the prescribed treatment. In many cases, the respiratory staff was busy with other, more critical patients or were unaware of the order because it was not on their respiratory task list. ISMP noted that many respiratory therapists rely on their daily task list to determine which patients need treatments.

Numerous errors were also attributed to mix-ups with nebulizer vials, as these vials are similarly packaged and can be easily confused. Common errors include mix-ups between albuterol and the combination product of albuterol and ipratropium, 3% and 7% hypertonic saline, and dornase alfa and tobramycin. Some errors also occurred when the wrong dosage or route (e.g., 40 mg vs. 20 mg; oral vs. inhalation) of the medication was given. Look-alike containers have also contributed to errors, such as artificial tears or pediatric oral solutions being confused with nebulized medications, or vials of diluents being confused with medications packaged in similar containers.

Many other errors were attributed to staff overrides of automated dispensing machines, in which staff inadvertently grabbed the wrong medication. In addition, lack of an available point-of-care barcode scanning system or bypassing of these systems was associated with incorrect administration of nebulizer treatments. Various equipment issues also led to nebulizer errors. In one example cited by ISMP, a malfunctioning ventilator circuit during nebulization caused medication to back up in the nebulizer cup.

The report also includes safe practice recommendations.

For the full article, please visit for the May 2018 issue of Pharmacy Today.