ISMP’s Top COVID-19–Related Medication Safety Errors

Drug Topics Journal, Drug Topics February 2021, Volume 165, Issue 2

The presentation discussed the pandemic’s effect on medication safety and provided recommendations to hospitals.

The coronavirus disease 2019 (COVID-19) pandemic triggered medication safety concerns related to drug and medical supply availability across the health care system.

A session during the American Society of Health-System Pharmacists 2020 Midyear Clinical Meeting and Exhibition, held virtually December 6-10, 2020, addressed the effects of COVID-19 in the annual medication safety update from the Institute for Safe Medication Practices (ISMP).1

During the presentation, Christina Michalek, BS, RPh, FASHP, medication safety specialist and administrative coordinator for the Medication Safety Officers Society at ISMP, discussed top COVID-19–related medication safety issues that occurred in 2020 and recommendations for mitigating harm connected to some of them.

Repositioning Infusion Pumps

At the start of the pandemic, health care providers were faced with dwindling supplies of personal protective equipment (PPE), and many hospitals employed strategies to preserve PPE and limit staff exposure to COVID-19. “Some of the choices that were made really affected safe medication practices,” Michalek said.

One of these choices involved moving infusion pumps outside the critical care rooms of patients with COVID-19, according to Michalek. However, she noted several challenges and risks associated with this strategy:

  1. Supply availability of extensions sets
  2. Mechanical issues, such as delayed occlusions alarms at low flow rates, more frequent alarms at high flow rates, and affected flow rate accuracy
  3. Need for increased priming volume because of length of tubing
  1. Effects on barcode scanning and double-checks

“This definitely presented some challenges,” Michalek said. “Throughout, ISMP tried to represent the risks so that everybody could make the best and most informed decisions.” 

Drug Shortages and Importation

Although a long-standing issue, drug shortages have presented even more intense challenges during the pandemic. “We had many more critically ill patients, which really led to shortages of every drug that we use in mechanically ventilated patients,” Michalek said.

To combat some of these challenges, the FDA allowed importation of some medications. One of them was propofol. “Typically, in the United States, we use propofol as a 1% solution, and the FDA allowed us to import a 2% solution,” Michalek said. Because of shortages of propofol 1%, Fresenius Kabi received an emergency use authorization to bring in propofol 20 mg/mL (Fresenius Propoven 2%). 

“If the double concentration of this imported product is overlooked, we could have an overdose in patients,” Michalek said.

According to Michalek, ISMP recommends that hospitals:

  • Alert providers to the double concentration
  • Post wall charts and distribute fact sheets
  • Apply warning stickers to individual vials and cartons
  • Update drug databases and smart pump libraries
  • Affix a barcode if the international barcode does not scan

The FDA offers a wall chart on its website that can be posted in care areas, along with fact sheets designed for health care providers as well as patients and caregivers.

Absence of Cap Warnings on Vials of Neuromuscular Blocking Agents

Because of a shortage, Gland Pharma Ltd was allowed to manufacture and market vecuronium and rocuronium vials without the usual required labeling on the vial cap: “Warning: Paralyzing Agent.” The rest of the labels remained unchanged, but the caps were allowed to be marketed without the warning.

With the unlabeled caps, “it can be very easy for practitioners to mistake them for a normal medication,” Michalek said.

“We know with neuromuscular blockers, these are one of those high-alert medications that are so likely to be linked to harm in situations where they’re used as mistaken for another product.”

According to Michalek, ISMP recommends:

  1. Alerting staff about the absence of the usual warning statement
  2. Affixing auxiliary labels noting “Warning: Paralyzing Agent” to vial caps
  3. Storing the vials lying down (not cap up) so labels are visible
  4. Using barcode scanning during preparation and administration

Pharmacists can also visit for additional strategies on medication safety best practices.


  1. Michalek C, Grissinger M. ISMP Medication Safety Update for 2021. Presented at: American Society of Health-System Pharmacists 2020 Midyear Clinical Meeting and Exhibition; December 6-10, 2020; virtual.