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Medication Errors

Cohen, Michael R. ScD, MS, RPh

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doi: 10.1097/01.NURSE.0000659344.61195.11
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Avoid a cover-up

To reconstitute Revatio (sildenafil) suspension and generic equivalents (a phosphodiesterase-5 inhibitor indicated for the treatment of pulmonary arterial hypertension), the clinician needs to loosen the powder, add 60 mL of water, shake, then add another 30 mL of water and shake again for a final volume of 112 mL. As shown in the photo below, placement of pharmacy auxiliary labels on the outer carton of this product obscured part of the reconstitution directions—specifically, the part about adding another 30 mL of water. As a result, a pharmacy technician mistakenly reconstituted the product with only 60 mL of water instead of 90 mL total. The technician discovered the error the next day while reconstituting another Revatio oral suspension. The patient received one dose of the incorrectly reconstituted suspension but experienced no adverse reactions.

Auxiliary pharmacy labels obscured a portion of the reconstitution directions for Revatio oral suspension.

Pharmacy labels obscuring critical information on manufacturer product labels is an ongoing problem. In another incident, ropivacaine (a local anesthetic) prescribed for epidural infusion was infused via an I.V. catheter. Investigation revealed that a pharmacy label had been placed over a portion of the infusion bottle label that stated, “Not for intravenous administration.” The nurse infused it I.V. because it looked like other I.V. piggyback infusions.

Pharmacists and pharmacy technicians must not obscure important information when auxiliary labels, price stickers, or other labels are affixed to medication containers. Nurses who encounter medications with partially obscured labels should review the package insert or contact the pharmacy for instructions.


Dueling bar codes

The Institute for Safe Medication Practices (ISMP) has received reports of nurses scanning the wrong bar code on B. Braun Duplex containers of ceFAZolin injection, a semisynthetic cephalosporin (see photo at upper right). These and other B. Braun Medical I.V. products, including large volume parenteral I.V. bags, have two linear bar codes. For ceFAZolin Duplex containers, the upper linear bar code is for scanning the lot number and expiration date, although it is not clear if hospital pharmacies take advantage of this bar code. The bar code beneath this one is more important because it contains the national drug code number for product identification as required under the FDA Bar Code Rule.

An unsuccessful scan may occur because a nurse scans the wrong bar code or because the scanner hits and “reads” the uppermost bar code first, then sounds an alarm because this bar code is not used for product identification. The person who reported the issue to ISMP mentioned that scanning errors occur frequently at this hospital, which has led to nurse alert fatigue, time-consuming calls to the pharmacy, and delays in medication administration.

Nurses are confusing the two linear bar codes on B. Braun Duplex containers (see arrow).

ISMP has been in touch with B. Braun to suggest moving the upper bar code to another location far away from the product identification bar code or, better yet, replacing the uppermost bar code with a two-dimensional (2D) bar code. Appearing as a small square or rectangle containing many dots, a single 2D bar code can hold a significant amount of information. B. Braun has agreed to look into the situation.

If nurses are not using the lot number and expiration date (upper) bar code, hospitals should consider completely blocking out that bar code on the label with a marker to direct nurses to scan the correct bar code for product identification. ISMP encourages nurses to email to report whether they routinely scan the upper bar code for lot number and/or expiration date to provide more information about how often the bar code is used.

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