Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook

Hazard warning!

From the Sept. 10,1997 Issue

In the monograph for penicillin G which appears in Neofax '97 (Acorn Publishers), a note emphasizes "Use only aqueous penicillin G for IV administration." We are concerned that this could lead to a misunderstanding that penicillin G procaine or penicillin G benzathine may be administered intravenously, similar to the case we reported in our August 28, 1996, issue (Penicillin G procaine: never "aqueous" enough for IV use). In that case, a part-time pharmacist received an order for 29,000 units of "penicillin G (aqueous crystalline) IV q 8 hours" to treat congenital syphilis in a neonate. Since he was unfamiliar with the term "aqueous crystalline," he referred to Facts and Comparisons for more information. While glancing at the monograph for penicillin G procaine, entitled "PENICILLIN G PROCAINE, AQUEOUS (APPG)," his eyes caught a sentence that read: "When high sustained serum levels are required, use aqueous penicillin G, either IM or IV." He failed to realize that this meant penicillin G potassium, which is also referred to as an aqueous or crystalline form of penicillin. Associating the terms "aqueous" and "IV" with the written order, and not realizing the paragraph actually contrasted penicillin G potassium with penicillin G procaine, he incorrectly dispensed penicillin G procaine for IV use. Fortunately, the infant suffered no apparent adverse effects. However, as we have been reporting, a Denver infant died last year after receiving an IV dose of long-acting penicillin. We are also aware of other cases where either penicillin G procaine or penicillin G benzathine has been given intravenously. We have contacted Acorn and asked for changes in the monograph. In the meantime, be sure to seek out copies of this book that may be in your medical, pharmacy or neonatal staff libraries. Find the monograph on penicillin G and mark prominently in the opening paragraph: WARNING: PENICILLIN G PROCAINE AND PENICILLIN G BENZATHINE MUST NEVER BE USED INTRAVENOUSLY. We also highly recommend a computerized warning for each of these drugs. Since these drugs are not commonly used, healthcare professionals may be prone to misunderstand the differences.

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved