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Medication Errors

Cohen, Michael R., ScD, MS, RPH

doi: 10.1097/01.NURSE.0000525992.44109.b0
Department: MEDICATION ERRORS
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Adrenaline: not for the eyes...don't leave “Meds to Beds” prescription bags at the bedside...beware these look-alike products

President of the Institute for Safe Medication Practices

The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or ismpinfo@ismp.org. Michael R. Cohen is a member of the Nursing2017 editorial board.

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ADRENALIN

The eyes shouldn't have it

A patient received Adrenalin (EPINEPHrine injection) via ophthalmic instillation to induce mydriasis during intraocular surgery. This is no longer an approved indication for this brand of EPINEPHrine. Fortunately, the patient wasn't harmed.

At one time, Par Pharmaceutical's 1 mL Adrenalin vials listed induction and maintenance of mydriasis during intraocular surgery as an approved indication because this formulation didn't contain preservatives harmful to the eye. The Adrenalin brand of EPINEPHrine packaged in 30 mL vials never had that indication because it is formulated with preservatives.

In September 2016, the manufacturer submitted a supplement to the FDA to add tartaric acid and to add or adjust the amount of other excipients in the 1 mL vial to extend the drug's shelf life to 24 months. At that time, the manufacturer also removed the mydriasis indication from the labeling. However, although the label on the 30 mL vial states Not for Ophthalmic Use, the label on the 1 mL vial does not, as shown above. The company sent out a letter to inform pharmacists of the change in indication, but the information may not have reached ophthalmologists and some remain unaware that Adrenalin is no longer indicated for intraocular surgery.

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ISMP has asked Par Pharmaceuticals to clarify the labeling on the 1 mL product. Clinicians should know that at least one other brand of EPINEPHrine is available and approved for induction and maintenance of mydriasis during intraocular surgery.

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“MEDS TO BEDS” PROGRAMS

Don't leave prescription bags at the bedside

In a recent close call, a nurse gave a hospitalized patient his morning medications. The patient then opened the bag of discharge medications that had been left at his bedside and nearly took the same medications again.

The medications had been left at the patient's bedside in accordance with the facility's “Meds to Beds” program. These increasingly popular programs bring prescription medications to the patient's bedside prior to hospital discharge and may include patient education about the medications and follow-up by a pharmacist postdischarge. Some community pharmacies have contracted with hospitals to perform these services, or they may be provided by the healthcare system's ambulatory care pharmacy. Besides convenience, benefits may include better adherence to medication regimens and fewer patient readmissions.

However, the program isn't without danger, as the report described above illustrates. Because of the risk of medication errors, a pharmacy technician or assistant shouldn't simply drop off the medications or leave them on the patient's bedside table.

Nursing and pharmacy staff must be aware of this issue, and patient education should be considered imperative for “Meds to Beds” programs. One additional safety strategy is to affix an auxiliary label to the bag containing the medication(s) to remind the patient that the medications are for use at home only, not in the hospital.

Medications should never be left unsecured at the bedside before patient discharge. After a pharmacist reviews discharge medications with the patient, he or she should follow a facility protocol establishing where to secure medications until the patient's discharge and what to do if the patient isn't in the room at the time of delivery.

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LOOK-ALIKE PRODUCTS

Labels don't speak volumes

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Marketed by CSL Behring, AlbuRx 25 (albumin [human] 25% solution) is available in 50 mL and 100 mL containers, but the outer cartons are the same size and color, as shown below. Only by scrutinizing the labels can you see the volume difference. Packaging similarities make several other CSL Behring products susceptible to this type of mix-up; for example, AlbuRx (albumin [human]) and Privigen (immune globulin I.V. [human]) could be mixed up because their packages are styled similarly. The Institute for Safe Medication Practices recommends that pharmacies dispensing CSL Behring products scan each container's bar code prior to dispensing. Circling the volume or adding an auxiliary label may also help prevent errors.

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