Medication Errors

BY MICHAEL R. COHEN, ScD, MS, RPh PRESIDENT OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES

LOOK-ALIKE DRUGS spironolactone, which could lead to (Prograf) capsules instead of Astagraf These tablets are hyperkalemia. Or, if indapamide is XL. All tacrolimus products were in mistakenly dispensed instead of the same drop-down menu because almost twins spironolactone, a patient could expe- the hospital’s computer system oth indapamide 2.5 mg (ANI rience hypokalemia from taking two displayed all strengths of an active B Pharmaceuticals) and spironolac- tablets of indapamide. In addition, a ingredient in a single list. Also, tone 25 mg (Amneal Pharmaceuti- patient who uses online tablet/ immediate-release and extended- cals) are round white tablets that are capsule identification resources release tacrolimus products are avail- virtually identical in color, size, and could easily misidentify these tablets. able in similar 0.5 mg, 1 mg, and 5 shape (see photos below). In addi- Pharmacists should ensure that both mg strengths, which may increase tion, indapamide has an imprint brands are not stocked in the pharmacy. the potential for confusion between code of ANI 511 and spironolactone There are alternative manufacturers, the two dosage forms. The error was has a very similar imprint code, AN especially for spironolactone 25 mg. discovered when the patient noticed 511. As shown in the photos, these Technically, these products may a difference in how the capsules qualities make them extremely dif- meet FDA requirements that tablets looked compared with prior refills ficult to tell apart visually, setting the be clearly marked or imprinted with a and reported it to the pharmacy. To prevent this type of error, the Institute for Safe Medication Practices (ISMP) recommends dis- playing the brand name of tacrolimus extended-release formulations (for example, Astagraf XL or Envarsus XR) on medication ordering and ver- ification screens to help differentiate Because of similar size, shape, and imprint code, indapamide 2.5 mg (left) looks very similar to spironolactone 25 mg (right). them from immediate-release tacroli- stage for a medication error. In com- code that, in conjunction with the mus such as Prograf and generic munity pharmacies, both medication product’s size, shape, and color, per- formulations. When prescribing bottles might be on the work counter mits the unique identification of the immediate-release tacrolimus, pro- at the same time; for example, a drug product. However, to prevent viders should use only the brand or patient might have prescriptions for confusion, the best solution would be generic name without modifiers such both indapamide, a thiazide-like for one of the companies to volun- as “IR” for immediate-release. Using diuretic, and spironolactone, which tarily change the tablet code and tablet generic names with abbreviated modi- helps manage potassium loss from appearance. fiers can introduce confusion because indapamide. Given that the tablets the meaning of modifiers such as IR look identical, pharmacy staff could and extended release (ER or XL) can easily return unused tablets from a TACROLIMUS vary depending on the manufacturer. counting tray to the wrong bottle or Using generic name ISMP published a review of multi- robotic dispensing container, and factorial causes of tacrolimus medica- then later mistakenly dispense the invites confusion tion errors, including confusion with wrong medication to another patient. acrolimus is an immunosuppressant the various strengths and formula- Routine safety measures such as Tindicated to prevent organ rejection. tions, look-alike names, and prepara- reading container labels and scan- A prescription for oral tacrolimus tion errors. Read it at www.ismp.org/ ning bar codes are unlikely to pre- extended-release (Astagraf XL) 3 mg node/182. ■ vent this type of error. daily was intended to be dispensed The reports described in Medication Errors were received Mixing up these two drugs could from a hospital outpatient pharmacy through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to be harmful. If spironolactone tablets using three 1 mg extended-release the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or [email protected]. were placed into an indapamide con- capsules for each dose. However, Michael R. Cohen is a member of the Nursing2020 tainer, spironolactone might be dis- the pharmacist mistakenly selected editorial board. pensed to patients who already take tacrolimus 1 mg immediate-release DOI-10.1097/01.NURSE.0000697228.93363.eb

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