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Safety Brief: Label miscommunication

From the July. 16,1997 Issue

An ICU nurse prepared an infusion of phenylephrine 25 mg/250 mL, or so she thought. The vials of phenylephrine she was using from Gensia state in bold print "1%"; the drug name and "10 mg/mL" appear in smaller print, partially obscured by a red-pink color band. The nurse thought that each vial contained 1 mg and prepared the infusion using 25 vials (250 mg/250 mL)! The infusion was hung by another nurse on the next shift, and the patient's systolic blood pressure rose to 208 mm Hg. The nurse suspected something was wrong with the infusion; after she remade and hung the infusion, the patient's systolic blood pressure decreased to 100 mm Hg. ISMP has been in touch with Gensia about this and similar errors we feel are tied to the use of a distinctive color band on the label. The company plans a label revision for its product line in the near future. Inadequate quality assurance also contributed to this error. Using more than one or two dosage units (vials, ampuls, etc.) to prepare a single dose should be a red flag unless a specific procedure addresses situations where no alternative exists (e.g., use of vasopressin ampuls in treating bleeding esophageal varices requires several ampuls). Many ICUs also lack the environmental controls (lighting, space for drug storage and preparation, isolation from activity and interruption, etc.) necessary for safe IV drug preparation. For patient safety, hospitals should support programs which centralize the IV preparation process in the pharmacy, where proper controls exist. Of course, the pharmacy must demonstrate that it can respond to the unit's needs in timely fashion.


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