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Mistakes in the mist?



President of the Institute for Safe Medication Practices

Mucolytic products such as acetylcysteine (Mucomyst), which is approved for bronchopulmonary use, are intended to be administered by nebulization. However, acetylcysteine is also administered by mouth for certain off-label applications, such as treating acetaminophen overdose.

In 2004, the FDA approved an I.V. formulation of acetylcysteine (Acetadote) to treat patients with acetaminophen overdose. Now acetylcysteine is being administered by oral, I.V., and inhalation routes, increasing the risk of confusion—especially because the nebulizer product comes in a vial with a rubber stopper like the injectable product.

Recently, an error was averted when a nurse called the pharmacist to ask whether the nebulizer drug received from the pharmacy was compatible with the patient's I.V. fluids. In another case, a patient was given the nebulizer formulation I.V.

To prevent mix-ups, the pharmacy could remove oral doses of the nebulizer acetylcysteine solution from the original vial and place them in oral solution bottles with a label showing the drug, strength, and route. Similar labels should be placed on vials dispensed for I.V. administration and nebulization. A caution should appear on the MAR clarifying which product to use. Finally, double-check with the prescriber if the administration route is unclear.

The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at or the United States Pharmacopeia (USP) at You can also call ISMP at 1-800-FAIL SAFE or send an e-mail message to

© 2005 Lippincott Williams & Wilkins, Inc.