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Action may be necessary to prevent confusion between Roxanne's oral liquid opiate products

From the December 18, 1996 issue

Problem: Nursing staff on a long-term care/palliative care unit notified the hospital pharmacy that an order for 60 mg of Roxanol® (morphine sulfate) liquid every 4 hours for pain had just been written for a patient with advanced AIDS. Pharmacy responded but dispensed a 30 mL bottle of Roxicodone Intensol® (oxycodone) instead of a 30 mL bottle of Roxanol® . At least four nurses incorrectly administered 60 mg of oxycodone instead of 60 mg of morphine for 7 doses in a row. Since 30 mg of oral oxycodone is approximately equivalent to 30-60 mg of oral morphine, the patient received as much as twice the intended amount of opiate on each occasion. However, the patient did not experience any adverse effects. The error was later discovered by a nurse who herself had made the same error three weeks earlier.

Several factors probably contributed to this mix-up. Both opiate product names begin with "Rox." They may be stored right next to one another in alphabetical order. Both are packaged in 30 mL bottles. Both have a 20 mg/mL concentration and are colorless solutions. Both items are sold by Roxane Laboratories and use characteristic brown on white labels with a similar layout and identical fonts for label text. All of these similarities may have contributed to the most important problem of all: pharmacists and nurses did not read the label of the container before dispensing or administering oxycodone.

Similar problems have occurred in the past with another Roxane product, Roxicet® (oxycodone 5 mg and acetaminophen 325 mg in 5 mL) which has been confused with Roxanol®. A patient who was supposed to receive 10 mL of Roxicet® got 10 mL of morphine concentrate instead (200 mg)1. Another unrelated problem, but one that is at least as serious, is confusion between the 20 mg/mL Roxanol® and Roxane's morphine oral solutions in concentrations of 10 mg/5 mL or 20 mg/5 mL. Mix-ups between these items have resulted in massive opiate overdoses2. .

Safe Practice Recommendation: Practitioners should take error potential into account where these products are stored in proximity to one another in the pharmacy, in automated dispensing modules or within nursing unit narcotic floorstock. The pharmacist who reported the Roxanol-Roxicodone mix-up is trying to identify another source of supply for one of the items so that it will be labeled differently than the remaining Roxane product. If two or more of these Roxane products are in use, remind your staff of name similarities and consider adding an auxiliary label to each container to call attention to the differences. Staff education is also needed to prevent confusion between Roxanol® and other morphine solutions. Roxanol® should not be kept in floorstock unless the unit treats many patients with chronic pain. Use the lower concentration of morphine in unit dose form (available from Roxane) when liquid morphine is needed and the dose is relatively low.

We wish that companies would refrain from incorporating their own name into their brand names. When this is done for more than one of their products, it increases the chance of dispensing errors because of confusion over the name similarities. In general, manufacturers of multisource drugs should weigh benefits of assigning brand names to their products against the difficulty they create for practitioners. We have encouraged Roxane to work with practitioners to identify any product-related medication errors and to develop effective preventive measures. [N, P, T]

References: 1. Cohen MR. Roxane trademark practices leading to confusion. Hosp Pharm 1993;28:1258. 2. Cohen MR. Milliliter dosing mishap. Nursing 1994 (Aug);24:15.

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