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Many wrongly believe long-acting parenteral penicillins are for intravenous injection



From the June 30, 1999 issue

PROBLEM: It is very discouraging for us to write about yet another error involving IV administration of long acting parenteral penicillin (penicillin G benzathine and penicillin G procaine; BICILLIN CR), a drug that should be administered IM only. When a 2-year-old child arrived in the recovery area after undergoing an adenoidectomy, a nurse noticed a thick white material that appeared to be stuck to the inside of the IV tubing. Flushing the line did not clear the tubing. Further investigation revealed that a dose of Bicillin CR, which was available as floor stock in the ambulatory surgery unit, was sent to the OR with the patient. At the conclusion of the case, the certified registered nurse anesthetist (CRNA) noted that the Bicillin CR had not been administered and asked the surgeon if he wanted it given. When the surgeon answered affirmatively, she administered it IV instead of IM since the child was awake and would experience pain from an IM injection. Fortunately, the child had no serious reaction. As in other similar cases reported to ISMP, the manufacturer's warning on the syringe that the drug is intended for "IM use only" is not prominent; thus, it was overlooked. Amazingly, after the error, an informal survey of the OR staff at this hospital revealed that at least 5 other CRNA's thought the drug could be administered IV! In fact, one recalled administering Bicillin CR to a patient intravenously just a few weeks prior. Similarly, findings from a survey of neonatal nurses and nurse practitioners indicate that the knowledge deficit with various forms of penicillin G is not confined to isolated cases (Horns KM, Gills MB. Neonatal nurse knowledge of penicillin therapy. The NANN Pages: National Association of Neonatal Nurses; October 1998). The survey revealed that 35% of neonatal registered nurses (RNs) and 30% of neonatal nurse practitioners (NNP) were unable to identify the correct route of administration for penicillin G benzathine. The usual dosage of penicillin G was unknown to 34% of the total sample of RNs and NNPs, and only 12% of RNs and 20% of NNPs demonstrated correct knowledge about the various types of penicillin G.

SAFE PRACTICE RECOMMENDATION: It is likely that some practitioners at all clinical sites lack knowledge about the correct route of administration of penicillin G benzathine, penicillin G procaine, and combinations of these long acting parenteral penicillins. Fortunately, the child involved in this case was not harmed. However, errors, sometimes fatal, continue to occur with these products. It is not enough to assume that those without requisite knowledge will seek out the necessary information in drug reference texts. Unfortunately, many reference texts contain ambiguous or misleading information about the various forms of penicillin, such as referring to both penicillin G benzathine and penicillin G potassium as "crystalline penicillin" and "aqueous suspension" while noting that "aqueous crystalline penicillin G" can be administered IV. Some reference texts, especially those that are outdated, may not clearly warn practitioners that penicillin G benzathine and penicillin G procaine can be administered IM only. Further, some practitioners confuse long acting penicillins with lipid-based products that can be give IV and are also white and milky looking, such as IV lipids or propofol. To promote safe use of long acting penicillins, we urge facility-wide education for all practitioners involved in medication use, including new staff during orientation. Furthermore, the pharmacy should apply distinctive auxiliary warning labels to these products to warn practitioners that the drugs are intended for "IM use only." We've asked FDA to work with manufacturers of penicillin G benzathine and procaine to enhance syringe warnings. One additional safety precaution: provide patient care units with up-to-date reference texts annually and discard out-dated texts, which may provide unclear information about long-acting penicillins.

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