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Action Needed! Daptacel and Adacel mix-ups continue

From the December 2006 issue

As 2006 nears a close, we were troubled to learn about the repeat of an error that we published in August 2006—administration of the pediatric vaccine DAPTACEL (diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed [DTaP]) instead of ADACEL (tetanus toxoid and reduced diphtheria toxoid and acellular pertussis vaccine adsorbed [Tdap]). In this case, the error involved 80 hospital employees, 5 of whom developed swelling and fever after administration. This cluster of reactions led to investigation and discovery of the error by a nurse practitioner in occupational health. In this case, the pharmacy incorrectly sent Daptacel to the hospital’s employee health department. The similarity in appearance and names of these two products, both from sanofi pasteur, are no doubt contributing factors in each of the reported errors, including this one. While the cartons do differentiate the formulations by the abbreviations DTaP and Tdap (terminology which many practitioners may not be familiar with), only one product, Adacel, states the intended age range on the face of the carton.

We, in healthcare, cannot in good conscience let this error-prone packaging continue without imploring FDA and sanofi pasteur to pursue safer labeling and packaging of these products. It is time to stop relying solely on safety briefs and alerts to prevent these errors and end the unnecessary mix-ups and follow-up screenings the victims of this error have had to endure. FDA and sanofi pasteur need to accept responsibility for resolving this unacceptable risk. It is time for some action!
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