Error Alert
Institute for Safe Medication Practices, Horsham, PA
Patients, particularly pediatric patients, can be harmed when medications are reconstituted improperly, or not reconstituted at all. In the July 2019 issue of Pharmacy Today, we discussed multiple reports of patients being dispensed medications before they were reconstituted, or medications that were reconstituted with the wrong amount of diluent. In one case, an infant was taken to the emergency department after an antibiotic overdose.
However, these previously discussed cases are not the only way reconstitution errors occur.
The Institute for Safe Medication Practices (ISMP) has received multiple reports in which the wrong diluent—such as isopropyl alcohol or formalin—was used instead of water, with some errors resulting in permanent patient harm.
Errors reported to ISMP
Case 1
A bottle of valganciclovir powder for oral solution was accidentally prepared using isopropyl alcohol 70% instead of water. The reconstituted product was dispensed, and one dose was administered to a child. The child’s parents were contacted the following morning.
Fortunately, home observation was recommended, and the child showed no adverse effects. Investigation of the event uncovered that there were 2 different labels on the bottle of isopropyl alcohol used; one read “isopropyl alcohol 70%” and the other “distilled water.”
The bottle containing isopropyl alcohol had been prepared and labeled in the pharmacy using a previously labeled container that contained distilled water.
Case 2
Multiple patients were harmed when antibiotics were inadvertently reconstituted with 10% formalin solution (3% formaldehyde and 15% methanol) in 2 pharmacies that stocked gallon jugs of distilled water as well as 10% formalin (for nearby laboratories or surgical centers). Empty jugs labeled “distilled water” were accidentally grouped with empty jugs labeled “formalin” that were awaiting refill. After incorrectly filling all the jugs with formalin, the containers labeled “distilled water” were returned to stock with other jugs of distilled water. Later, they were used to reconstitute antibiotic suspensions.
More than 35 children took the tainted antibiotics. Several required hospitalization for vomiting, but none suffered permanent injuries.
Case 3
A pharmacist reconstituted amoxicillin suspension with a 50% alcohol and water solution instead of water. Both containers were on a counter beside each other.
The pharmacist accidentally grabbed the alcohol solution, which was used for dermatological preparations, to prepare the suspension.
Case 4
A staff member identified 70% isopropyl alcohol from NxN Sanitize in packaging that looks just like a similar-sized bottle of drinking water.
Due to the risk that this could be mistaken for a bottle of water, the pharmacy removed this product from the pharmacy’s inventory.
Risk-reduction strategies
Examine your supply of chemicals and compounding solutions. Discard any that are not regularly used. For chemicals that must remain, never store them near drugs.
Determine if any could be confused with another product due to the container’s color, size, or shape; the product’s name; or the solution’s color/clarity.
Place prominent warning labels on non-drug products.
To minimize the risk of mix-ups, pharmacies should not store or supply chemicals (e.g., glacial acetic acid, formalin, phenol) for laboratories, surgical centers, or physician practices.
Pharmacies also should not reuse or relabel empty containers, especially if they held another substance.