Medication Safety
Institute for Institute for Safe Medication Practices, Horsham, PA
A pharmacy inadvertently applied a labetalol label to the manufacturer bottle of lamotrigine. The patient prescribed labetalol suffered repeated adverse effects after taking their mislabeled, incorrect medication.
Problem
A patient’s daughter recently reported that one of her parents had been prescribed the b-blocker labetalol. The prescriber had ordered labetalol 200 mg with instructions to take one tablet by mouth 2 times a day. After taking medication from a bottle recently dispensed by the pharmacy, the patient fell 4 times within a 48-hour period and required a 2-week admission to the hospital. The patient was then transferred to a rehabilitation facility.
After 2 weeks at the rehabilitation facility, the patient was discharged home, feeling well and able to engage in some of their normal activities, including shopping and assisting with yard work.
However, after 2 days at home and resuming their home medication regimen, the patient began to exhibit an array of symptoms, including stomach pain, blurred vision, nausea, neck pain, weakness, mood swings, and confusion. The patient was transported to the emergency department for evaluation. Testing conducted in the emergency department didn’t identify any obvious causes of the patient’s symptoms. The patient was discharged back home and advised to drink fluids, rest, and follow up with their primary care provider. However, once the patient was home, the same symptoms continued.
It was at this point that the patient asked their daughter to check the medication received from the pharmacy.
The daughter identified that the antiseizure agent lamotrigine 200 mg tablets had been dispensed, not the prescribed labetalol.
The pharmacy had applied the pharmacy label for labetalol to a manufacturer’s bottle of lamotrigine. As a result, the patient had been taking 200 mg of lamotrigine twice a day, a dose used for patients with epilepsy, but which requires titration in order to reduce the risk of severe or potentially fatal cutaneous and other hypersensitivity reactions.
Safe practice recommendations
While we do not know the details of how this error occurred, there are several strategies that can be implemented to prevent these types of wrong-drug errors. If not already in play, install and use barcode verification during dispensing. Scan each package or container used to fill a prescription.
If multiple bottles or cartons are required to fill a prescription, work with the pharmacy software vendor to enable scanning of each bottle or carton to ensure all bottles and cartons are the correct medications.
Implement a standard workflow process to ensure pharmacy staff generate the prescription label(s) for one patient at a time and then fill that patient’s prescription(s) before printing labels for or working on another patient’s prescription(s). Consider using baskets or bins to keep all prescriptions and labeled containers together for one patient together. When affixing the pharmacy label to a manufacturer’s container, avoid covering critical information (e.g., the drug name and strength).
Standardized processes should be developed to guide the pharmacist’s final verification of a medication. Have the computer system alert the pharmacist during product verification if barcode scanning was bypassed during filling.
At the point-of-sale, have the patient review the pharmacy labels and contents of each prescription container to check that the medication is correct—even if this requires opening the bag and drug container. If the product is shipped to the patient, instruct them to carefully inspect the product upon receipt, comparing the product name and quantity to what is listed on the pharmacy label. ■