Medication Safety
Institute for Safe Medication Practices, Horsham, PA
The Institute for Safe Medication Practices (ISMP) has published several cases of medications being dispensed to patients before they were properly reconstituted. Most of the cases involved pediatric patients who received overdoses of antibiotics when their parents administered the drug powder to their children. Other cases involved oral suspensions that had been inappropriately mixed (e.g., not enough diluent was used to reconstitute the medication powder). Unfortunately, ISMP continues to receive reports of this type of error.
In one recent case, the pharmacy dispensed amoxicillin for oral suspension as a powder. Thankfully, the child’s parent, who is a nurse, recognized that the medication needed to be reconstituted prior to administering a dose. When the parent called the pharmacy to inform them of the error, the pharmacy hung up on them.
In fact, the child’s parent had to make multiple phone calls to the pharmacy before they were able to speak to someone. The pharmacy staff indicated that the pharmacy was getting ready to close and therefore the child’s parent could not speak to a pharmacist. As a result of the error, the child had to wait until the next day to start their antibiotic.
In another recent case, a 10-month-old child was prescribed amoxicillin with instructions to receive 4.7 mL twice a day for 10 days. At home, the child’s parents were following the instructions but ran out of medication after just 6 days. When they returned to the pharmacy to report the situation, they were informed that the pharmacy’s machine that is supposed to dispense the correct amount of water for reconstitution was not calibrated correctly.
As a result, the patient’s amoxicillin had been reconstituted with less water than indicated, producing a suspension with a higher drug concentration. The parents reported that the patient was experiencing dark, loose stools, fussiness, nausea, and poor appetite.
To safeguard the dispensing of oral suspensions that require reconstitution, consider the following risk-reduction strategies:
Incorporate technology at the point of sale that will alert pharmacy staff that the prescription needs to be reconstituted. Explore options to have the alert be interactive, requiring the staff person to confirm that the medication has been reconstituted.
Add a note or label to the prescription receipt, or use some other distinct visual cue (e.g., a brightly colored “need to mix” card) indicating that the medication needs to be reconstituted prior to dispensing.
Place the actual product container that requires reconstitution in a separate area (e.g., not with other medications in the will-call area awaiting pickup, not bagged with other prescriptions for the patient).
Ensure that admixture technologies are tested and calibrated on a regular basis and according to manufacturer recommendations.
Establish a process to verify that the correct amount of liquid has been measured and used to reconstitute drugs.
After the product is reconstituted, the product should be given to the pharmacist, along with any other prescriptions, to counsel the patient on how to measure the medication. Use the teach-back method when educating patients. Have the caregiver or patient demonstrate how they will measure and administer the dose to validate learning.
At the point of sale, open the bottle with the patient or caregiver to check that the contents have been reconstituted.
Ensure that an appropriate metric dosing device, which corresponds to the instructions on the label, is provided with the product.
Include specific product descriptions on the prescription label (e.g., orange-flavored, white, opaque liquid) that will cue the consumer that they should be receiving an oral liquid product. ■