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Medication Errors

Cohen, Michael R., ScD, MS, RPh

doi: 10.1097/01.NURSE.0000554243.89883.d7

Confusing label invites a twofold overdose of oral potassium solution...avoid abbreviating drug names...lower dosage is not always a “junior” with epinephrine autoinjectors


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, 1-800-FAIL Safe, or Michael R. Cohen is a member of the Nursing2019 editorial board.

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Confusing label invites a twofold overdose

Pharmacy and nursing staff may not notice that a unit-dose cup of potassium chloride oral solution from Atlantic Biologicals, labeled primarily as 20 mEq per 15 mL, contains 30 mL, or 40 mEq. The fact that it contains 30 mL appears on the label, but a practitioner may not see this because the statement “RX ONLY” is inserted on the line above (see photo). In that case, someone dispensing or administering this product might mistakenly give 2 unit-dose cups (80 mEq) when a patient is supposed to receive only a 40 mEq dose (1 unit-dose cup).



To avoid errors, the label should list the drug concentration as the amount of drug per container volume, or 40 mEq per 30 mL. As shown in the photo, organizations can improve safety by adding an auxiliary label restating the amount of potassium chloride contained in the unit-dose cup.

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Cross (off) these T's

The FDA and the Institute for Safe Medication Practices recommend not using abbreviations for drug names, including “tPA” for a tissue plasminogen activator such as alteplase (Activase), a fibrinolytic agent, and “TXA” for tranexamic acid, an antifibrinolytic agent. An incident in which a patient received tranexamic acid instead of alteplase illustrates why.

Confusing “tPA” and “TXA” in his mind, a clinician removed tranexamic acid instead of alteplase from an automated dispensing cabinet (ADC). Because the ADC had accidentally been left on critical override from the night before, he was able to remove tranexamic acid for the patient without an order for the drug. After the wrong drug was administered, the error was discovered and the patient received alteplase as intended, but therapy was delayed.

Tranexamic acid is an antifibrinolytic agent commonly used in patients who are hemorrhaging or at risk for hemorrhage, so mixing it up with a tissue plasminogen activator can be harmful. Use of the abbreviation tPA has also contributed to confusion between alteplase and a different tissue plasminogen activator, TNKase (tenecteplase), which is sometimes improperly called TNK.

Alert prescribers to the risk of mental mix-ups between drug name abbreviations, especially similar ones such as tPA, TXA, and TNK. All healthcare professionals should refer to medications by their generic and/or brand names only, and prescribers should include the drug's indication with orders to further avoid confusion.

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Lower dosage is not always a “junior”

EPINEPHrine is dosed by weight when used to treat an allergic reaction or anaphylaxis, not by whether the patient is an adult or child. Patients weighing 30 kg (approximately 66 lb) or more should use a 0.3 mg injector. Those who weigh 15 to 30 kg (33 to 66 lb) need a 0.15 mg injector.

Generic auto-injectors list the metric strength only, 0.3 mg or 0.15 mg, as shown below. However, the brand name EpiPen auto-injector adds “Jr” as part of its designation for the 0.15 mg strength.



Both dosage strengths should be available for treatment in healthcare facilities. Practitioners unfamiliar with EPINEPHrine dosing may confuse the strengths if they expect to see the 0.15 mg dosage designated as “Jr.” Healthcare professionals must remember that the “Jr” designation will not appear on generic EPINEPHrine auto-injectors.

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