Practitioners' Reporting News

Timentin®—Confusion Between 3.1 gram & 31 gram Vials

Issued June 17, 2002

The USP Medication Errors Reporting Program received a recent report concerning the antibiotic Timentin® (ticarcillin disodium and clavulanate potassium), manufactured by SmithKline Beecham, indicating that a shortage of the 3.1 gram vials in the marketplace resulted in only the 31 gram pharmacy bulk package vials being available in the pharmacy.

The report describes a situation where an order for Timentin 3.1 gram was written for a patient after the hospital's pharmacy closed for the day. A nurse supervisor went into the pharmacy to obtain the product and finding only Timentin 31 gram, selected two doses, and delivered them to the patient care unit. The patient's nurse made the assumption that the entire vial contained the 3.1 gram dose and administered two separate doses, four hours apart, of the entire vial at the appropriate intervals. The nurse involved in the error misread the vial as 3.1 gram, not realizing that a 31 gram dose was being administered. The patient developed seizures, acute renal failure, congestive heart failure, and eventually died.

This error should serve as a reminder that caution is needed when allowing access to a pharmacy where pharmacy support is unavailable at certain hours. The reporter that submitted this medication error recommends that if pharmacy bulk packs are being stocked, extra outside warnings should be applied for the benefit of any healthcare practitioner who has access to the pharmacy after hours when a pharmacist is not available. Moreover, the reporter feels that a pharmacist should be on call, at least by telephone, and that access should not be allowed to restricted medications when a pharmacist is not available.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) has developed "Recommendations to Health Care Organizations to Reduce Errors Due to Labeling and Packaging of Drug Products and Related Devices." NCC MERP recommends reevaluation of existing storage systems for pharmaceuticals by health care organizations and establishment of mechanisms to ensure appropriate storage and location throughout the organization from bulk delivery to point of use. The following issues should be considered when applicable:

storage and location that will help distinguish similar products from one another;
storage and location of certain drugs, (e.g., concentrates, paralyzing agents) that have a high risk potential;
scope, access, and accountability for floor stock medications;
safety and accountability of access to pharmaceuticals in the absence of a pharmacist (e.g., floor stock, eliminate access to pharmacy after hours);
labeling and packaging of patient-supplied medications.

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.