Hazard Alert! TRAVASOL Amino Acid Injection in 2000 mL glass containers

From the June 6, 1996 issue of MSA Acute Care edition newsletter

Recently, the Clintec Nutrition division of Baxter Healthcare Corporation discontinued packaging 10% TRAVASOL Amino Acid Injection in 2000 mL glass containers. Instead, they are now packaged in 2000 mL VIAFLEX bags.
Although these containers are properly labeled by the manufacturer, several pharmacists have independently contacted the USP Medication Errors Reporting Program* (USP MERP) to express concern that the TRAVASOL container is too similar in appearance to Clintec’s 70% Dextrose Injection, also available in a 2000 mL VIAFLEX bag. The labeling on each container is printed in black which may be difficult to see upon the clear plastic containers, especially against a dark background. Also, to meet regulatory requirements, both containers use similar font and type size, including the same large boxed warning advising that the container is a pharmacy bulk package and not for direct injection. In addition, each item is originally packaged within a similar foil overwrap, using similar black print.

In one case, a patient erroneously received 70% dextrose instead of 10% amino acids. The
error was discovered the following morning when the 70% dextrose bag was noticed on the pharmacy’s automated IV compounder.

Mix-ups involving high concentration dextrose could prove fatal. If your hospital uses these
Clintec products, please be sure to address this potential error situation immediately. Reminding people to read labels is not enough. Staff education, careful solution storage, auxiliary labeling for the containers, and a temporary alternative for one of these products to help make one of them look different, may be considered. As described in our May 22, 1996 Safety Alert!, never rely on personnel and equipment alone. End product testing (e.g., refractometer, comparison of expected weight to actual weight) should always be conducted to assure that proper dextrose concentrations have been prepared.

Clintec Nutrition has been notified of this alert, and is taking this matter under advisement. Additional information will be made available in the next issue of ISMP Medication Safety Alert!

* The USP Medication Errors Reporting Program is operated in cooperation with the Institute for Safe Medication Practices, 320 W. Street Road, Warminster, PA 18974