Practitioners' Reporting News

And The Similarity Goes On

Issued April 30, 2004

The following cases were submitted to USP's Medication Errors Reporting (MER) Program between October—December 2003, and illustrate the confusion that may result from the similar labeling/packaging of products and the similarity of the drug products themselves. By sharing these cases with healthcare professionals, the USP Center for the Advancement of Patient Safety hopes that practitioners will become more and more aware of the safety issues surrounding product similarity—the informed practitioner is an empowered practitioner.

Case 1

Error Description: A pharmacy technician accidentally ordered atropine (for examination of the retina and optic disc) 0.5 mg syringes instead of the 1 mg syringes. Only one package of the wrong strength was ordered. Another technician noticed the ordering error when restocking the automatic dispensing cabinet. The reporting practitioner believes that the cause of this error could be the result of using the same color packaging for different strengths of the medication.


Photo of similar labeling/packaging*

Reporting practitioner's recommendation/action taken: The medication was returned to the pharmacy, separated from the rest of the stock, and labeled "Wrong Strength, Please Return." The incorrect strength was returned to the wholesaler so that it would not be in the facility. Unfortunately, the drug shortage situation has forced this facility to be increasingly creative in preventing similarity mix ups. Sometimes stocking look-alike products is unavoidable. In similar cases, the facility evaluates the areas that stock the potentially problematic medications and often uses "Note Dosage and Strength" stickers to draw attention to the potential for mix up. This facility is also careful to stock these identified medications in separate drawers or areas of the automated dispensing cabinets, as well as communicating these potential problems with staff.

Case 2

Error Description: An error occurred because of look-alike wrappers on B&O Supprettes® (manufactured by Polymedica Pharmaceuticals) and acetaminophen suppositories (manufactured by G&W Laboratories), both for the relief of pain. A B&O suppository was found in a bin with acetaminophen suppositories. It is believed that a nurse removed the B&O suppository from the automated dispensing system, did not administer it, and put it in the patient's cassette. When the cassette was returned to the pharmacy, a pharmacy technician assumed that the foil wrapped B&O (belladonna and opium) suppository was acetaminophen and placed it in the acetaminophen bin.


Photo of similar labeling/packaging*

Reporting practitioner's recommendation/action taken: The facility ordered acetaminophen suppositories with blue lettering on the package and is considering placing an identifier on the B&O suppositories.

CASE 3

Error Description: The size and cap color of Abbott's naloxone (for the reversal of opioid depression) 0.4 mg/mL and tobramycin (for infection) 80 mg/2 mL vials are similar. Both vials have an orange colored cap and similar size. The medications were stocked near each other in the picking station using the brand names (Narcan® and Nebcin®, respectively). Some of the tobramycin vials were placed in the naloxone bin, which were subsequently placed on a medication tray for a crash cart. During a code, it was noticed that the crash cart tray contained one vial of tobramycin instead of naloxone. Naloxone was also on the tray, so the patient was not affected by this error.


Photo of similar size vials and colored caps*

Reporting pharmacist's recommendation/action taken: The products were separated in the picking station and the facility is searching to find if one of the products can be purchased from a different vendor.

CASE 4

Error Description: Brethine® (a bronchodilator) was administered to the patient instead of Methergine® (for the prevention and treatment of postpartum and post-abortion hemorrhage). The patient did not have a lasting adverse outcome, but the potential existed because the patient's bleeding was not being controlled and the patient was symptomatic from receiving the Brethine. Both Methergine and Brethine are floor stock, but Methergine is kept in the refrigerator and Brethine is not. It is not known how, but the Brethine was placed in the refrigerator mixed in with the Methergine. The overwraps on both ampuls are amber colored, which makes it difficult to read; although the information is available on the paper backing. The medications are made by two different manufacturers, but both utilize the same type of packaging.


Front
Back
Photos of similar labeling/packaging*

Reporting medication safety officer's recommendation/action taken: The facility labeled the storage areas for both products so that the staff is cognizant of the look-alike problem.

CASE 5

Error Description: The pharmacy placed an Isuprel® (for ventricular arrhythmias) ampul in with the Lopressor® (for hypertension) ampuls in the cardiac support floor stock. Isuprel was removed from the stock and administered to a patient. Both products have the same blue stripe on the ampul and look very similar.


Front
Back
Photos of similar labeling/packaging*

Reporting pharmacist's recommendation/action taken: As the stock of Lopressor ampuls is depleted, the facility will be switching to a generic metoprolol single-dose vial to avoid this confusion in the future.

CASE 6

Error Description: Ivax Pharmaceutical's enalapril and lisinopril (both for hypertension) 10 mg bottles are too similar. The labels are identical except for the name and a small area denoting the color of the tablet (white or salmon). A pharmacy technician discovered the look-alike labels when an enalapril bottle was found in the lisinopril bin.


Photo of similar labeling/packaging*

Reporting pharmacist's recommendation/action taken: Verbally alerted all staff members to the problem and placed a "CAUTION" label on the bins.

CASE 7

Potential Error: The labeling of heparin (for thromboembolic disorders) and digoxin (for congestive heart failure) is so similar that if the labels are faced away from the reader, the Carpujects® could easily be mistaken for one another.


Front
Back
Photos of similar labeling/packaging*

Reporting practitioner's recommendation/action taken: An announcement identifying the similarity of these two products was created and distributed to the staff.

CASE 8

Error Description: The packaging of oxycodone (for the relief of pain) and Methylin™ (for attention-deficit/hyperactivity disorder) is so similar that a pharmacy technician grabbed one instead of the other. Both products were stored next to each other on the shelf. In addition, the actual drug product and imprint code are very similar; both have an "M" on one side and a "5" on the other, with the only difference being the diameter of the tablets.


Photo of similar labeling/packaging*


Methylin 5 mg
Oxycodone 5 mg
Photos of similar tablets and imprint coding (obtained from Mallinckrodt's Web site)

Reporting practitioner's recommendation/action taken: The products are now stored separately.

Do you have creative ways for resolving these and other similarity issues? Share your experiences with the MER Program. Other practitioners will benefit from your experiences and valuable insight.

Actual and potential medication errors can be submitted online at www.usp.org/patientSafety/mer/ or by requesting a reporting form at
1-800-23-ERROR (1-800-233-7767).

*Photos provided courtesy of the reporter or the Institute for Safe Medication Practices.


Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.