Practitioners' Reporting News

Total Bag/Vial Content Confusion

Issued May 31, 2005

The following summaries are a sample of reports submitted to USP's Medication Errors Reporting (MER) Program regarding total bag/vial content confusion.

Case 1

Error description: At the top right side of Baxter's heparin sodium in dextrose pre-mixed IV bag, within a red box, the label reads: 20,000 units HEPARIN (40 units/mL). Below the red box, printed in black lettering and on the left side of the bag, is the total volume 500mL.

Photo of Baxter's heparin sodium in dextrose pre-mixed IV bag*

At this facility, the majority of these bags are distributed via an automated dispensing machine and not labeled by the pharmacy. The facility has had three errors occur where infusion pumps have been set with a heparin concentration of 20,000 units/40 mL, rather than 20,000 units/500 mL. All three errors were discovered by nursing staff. In all three instances, the patients had subtherapeutic activated partial thromboplastin times with no other adverse effects. Due to the label's coloring and layout, attention is drawn to the red box and not the total volume contained in the bag.

Reporting pharmacist's recommendation: The problem was reviewed by a committee. Baxter has been alerted and the facility will increase nursing education about the issue. The facility has recommended to Baxter that they change their labeling to include the volume of the bag in the same color and in the same location as the total number of heparin units.

Case 2

Error description: GensiaSicor's phenylephrine injection vial is labeled as 1%, 10 mg/mL, 1 mL fill in a 2 mL vial (i.e., 10 mg total in each vial). The pharmacist dispensed two vials thinking there was 2 mL in each vial (i.e., 20 mg total in each vial to make a 30 mg drip), and gave them to a nurse during an emergency situation. Fortunately, there was enough overfill in each vial to make the drip and the nurse did not have to make a second trip to the pharmacy.

Reporting pharmacist's recommendation: The manufacturer should change the vials to state 10 mg/vial or remove the 2 mL vial information.

Case 3

Error description: Innohep® 20,000 units/mL (2 mL vial with a total vial content of 40,000 units/2 mL) was recently added to the facility's formulary. When the pharmacist added the new product in the pharmacy's computer system, the correct concentration of 20,000 units per mL was entered. However, where the pricing and dosing are calculated, the concentration was entered as 20,000 units per 2 mL-the size of the vial, not the total vial content. The error was discovered by another pharmacist the next morning when checking the label generated by the computer. A dose was dispensed the previous evening (at twice the ordered dose), but it was not administered because the nurse, who was not familiar with the medication, wanted to look it up in a reference and consequently omitted giving the drug. The unused dose was collected and brought back to pharmacy. The patient had no adverse consequences due to the omission.

Reporting pharmacist's recommendation: A second person should double check new injectable and liquid products that are entered into the computer system. These particular dosage forms involve entering the amount of medication per container and container size. Additional educational material for staff was disseminated regarding this medication. When a new product is added to the formulary, a more rigorous education plan should be put in place so that product information materials are abundant and easy to locate by staff.

Similar medication errors can be submitted to the MER Program via a secure online form or by calling 1-800-23-ERROR (1-800-233-7767) to request a reporting form.

*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.