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Medication Errors

Cohen, Michael R. ScD, MS, RPh

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doi: 10.1097/01.NURSE.0000757184.80085.c4
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In Brief


Preferred vs. legal name for transgender patients

A patient who identified as transgender was called by a preferred name but had not legally changed it, resulting in a delay of care during a cardiac emergency. When the patient coded, the team was told to remove medications from the automated dispensing cabinet (ADC) using the patient's preferred name; however, the patient's legal name, which was unfamiliar to the code team, was listed in the ADC. Although the electronic health record (EHR) included extra fields for the patient's preferred name and assigned sex at birth, ADCs receive only the legal name from the EHR and not the documented preferred name. Similar issues have also emerged in behavioral health settings.

To ensure standardization, vendors should consider updating ADC technology to allow the preferred name to transfer from the EHR. On medication labels, the patient's legal name and preferred name should both be documented accordingly. Healthcare professionals must recognize the potential for name confusion that this may cause during patient care and strive to treat all patients with respect and dignity while preventing medication harm.


Bar code scan indicates wrong drug

Two hospitals reported that McKesson's levETIRAcetam 250 mg unit dose blister packages (NDC 63739-795-10) have a bar code that scans incorrectly. LevETIRAcetam is an antiepileptic drug. While the bar codes on one side of a unit-dose blister package of 10 tablets scans properly, those on the other side indicate naproxen 500 mg, a nonsteroidal anti-inflammatory drug. The lot number reported in both cases is 0000124916. Based on visual inspection of the tablet and imprint code, however, one hospital reported that the tablets contained in the blister pack appear to be levETIRAcetam 250 mg.

Scanning the mislabeled packages may result in levETIRAcetam being placed in a bin assigned to naproxen in automated medication inventory storage devices such as the pharmacy carousel or ADC, ultimately contributing to wrong drug errors. For example, a nurse could retrieve the mislabeled levETIRAcetam thinking it is naproxen, scan it, get a match for the prescribed naproxen, and inadvertently administer the wrong drug to the patient. Conversely, if the mislabeled product is stored appropriately and retrieved for a patient for whom levETIRAcetam has been prescribed, a possible wrong drug alert may cause confusion and a delay in care.

McKesson Packaging is investigating, and the FDA has been alerted.


Adrenalin vials resemble COVID-19 vaccine vials

Vials of Adrenalin (EPINEPHrine) from Par Pharmaceutical resemble Pfizer-BioNTech COVID-19 vaccine vials. Both are approximately the same size and shape, with purple caps and mostly black print on white labels (see photo above). In two reported cases, EPINEPHrine syringes were mistakenly administered to patients instead of the COVID-19 vaccine, shedding light on the importance of separate storage of EPINEPHrine and COVID-19 vaccine syringes. The same mix-up could happen with similar-looking vials.

Similar-looking vials of Par Pharmaceutical's Adrenalin (left) and the Pfizer-BioNTech COVID-19 vaccine (right).

EPINEPHrine must be readily available to treat a rare anaphylactic reaction associated with the COVID-19 vaccines, but healthcare professionals should avoid storing these vials near COVID-19 vaccines. If possible, consider utilizing bar code technology that requires scanning before administration to ensure the right product is being administered (despite the fast-paced environment during emergencies). Additionally, the provision and use of ready-to-use EPINEPHrine autoinjectors instead of EPINEPHrine vials makes the drug look visually different than the Pfizer-BioNTech COVID-19 vaccine vial.

Wolters Kluwer Health, Inc. All rights reserved