Practitioners' Reporting News

Multiple Drugs Including "Intensol™" in Name Causes Dangerous Confusion

Issued August 8, 2001

The USP Medication Errors Reporting (MER) Program recently received a report of an error in which two different drugs with "Intensol™" in their brand names were confused, and a patient nearly received an antipsychotic medication, rather than the intended corticosteroid. "Intensol" is Roxane's trade name for all of its concentrated oral solutions with calibrated droppers.

The MER report describes a situation where an emergency room physician wrote an order reading " 'Intensol' 4 mL by mouth," to be sent home with the parents of a 2-year-old patient who presented to the emergency room because of difficulty breathing. The physician intended that the child receive the anti-inflammatory concentrated oral solution of the corticosteroid Dexamethasone (as Dexamethasone Intensol), though the order included neither a generic name nor an accurate brand name.

Because the order was written after pharmacy hours, the emergency room nurse and nursing supervisor filled the order. Unfamiliar with the product referred to in the physician's order, the supervisor looked up Intensol in the American Drug Index (ADI), and found an entry reading:

"Intensol. (Roxane) A system of concentrated solutions of drugs w/calibrated dropper".

This explanation was followed by a list of drugs manufactured by Roxane in the Intensol form. Despite being unsure of the order, the nurse and supervisor did not consult the physician or the pharmacist on call. The supervisor misinterpreted the ADI entry to mean that "Intensol" referred to a combination of those drugs, rather than a form of any one of them, and filled the order with the first medication on the list, the antipsychotic Chlorpromazine (Chlorpromazine HCl Intensol.) Chlorpromazine Intensol 30 mg/mL was obtained from the bulk liquid section of the pharmacy, and 4 mL of this solution was dispensed for the patient.

The error was prevented from reaching the patient only by chance. Shortly after the patient was sent home with the drug, the emergency room physician noticed the opened box of Chlorpromazine and questioned its presence because he had not ordered the product during that shift. Fortunately, the emergency room staff was able to reach the parents by telephone before the child received the dose.

Healthcare professionals are cautioned to exercise care in prescribing, dispensing, and administering products bearing "Intensol" in their brand names. "Intensol" is not the name of a specific drug or combination of drugs, but rather a trademark name of a type of concentrated oral solution system manufactured by one specific manufacturer, Roxane Laboratories. Further, some Intensol products are available in more than one concentration. For example, Chlorpromazine Intensol is obtainable as both a 30 mg/mL concentration and as a 100 mg/mL concentration.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), has a series of recommendations to prevent medication errors, and the following excerpts from the "Council Recommendations" may help reduce the chances of confusion of products in the Intensol form.

Recommendations to Correct Error-Prone Aspects of Prescription Writing, adopted September 4, 1996, include:

Prescription orders should include a brief notation of purpose (e.g., for cough), unless considered inappropriate by the prescriber. Notation of purpose can help further assure that the proper medication is dispensed and creates an extra safety check in the process of prescribing and dispensing a medication. The Council does recognize, however, that certain medications and disease states may warrant maintaining confidentiality.

The medication order should include drug name, exact metric weight or concentration, and dosage form. Strength should be expressed in metric amounts and concentration should be specified. Each order for a medication should be complete. The pharmacist should check with the prescriber if any information is missing or questionable.

Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications, adopted March 19, 1999, include:

The Council recommends that prescriptions/orders always be reviewed by a pharmacist prior to dispensing. Any orders that are incomplete, illegible, or of any other concern should be clarified using an established process for resolving questions.

Other recommendations regarding prescribing, dispensing, and administering are also available on the NCC MERP Web site.

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.