Another case of name confusion (what
else is Neu?)
From the July 29, 1998 issue
PROBLEM: An oncology patient had an appropriately
written order for Neumega® (oprelvekin) 3,500 mcg via
subcutaneous injection to treat chemotherapy-induced thrombocytopenia.
The patient was also receiving Leukine® (sargramostim,
GM-CSF) for a low WBC. The patient had been on these agents
as an outpatient, having received recent doses in the physician's
office just before being admitted for chemotherapy.
A pharmacist misread the order for Neumega as Neupogen®
(filgrastim). The 3,500 mcg dose was also misread and the
patient received Neupogen 350 mcg via subcutaneous injection.
The mistake was discovered after the second dose. The patient
was monitored for side effects or lasting sequelae from the
Leukine-Neupogen combination, but none were identified. The
patient's platelet count was not affected, and his WBC count
returned to normal limits within the next two days. However,
such an error could be serious if the patient was severely
thrombocytopenic and needed the platelet "boost" by Neumega
to prevent bleeding. Similarly, a leukopenic patient would
receive no benefit from administration of Neumega.
SAFE PRACTICE RECOMMENDATION: These names have identical
first syllables and both drugs stimulate the hematopoietic
system to increase production of components lost during cancer
treatment. The dose of Neumega is 50 mcg/kg/day. The dose
of Neupogen is 5 mcg/kg/day. Though a 10 fold difference in
the doses exists, the numbers are similar enough to cause
confusion, especially if staff are unfamiliar with the drugs.
In this case, the dose of 3,500 mcg (versus 350 mcg) went
unnoticed, possibly because both drugs were to be given subcutaneously
in a small volume. Neumega was not in the computer, but if
both drug names had appeared on the screen, it may have helped
the pharmacist choose the correct drug. However, it is also
important to exercise caution. Medication errors often occur
when two similar names appear together on the computer screen,
and someone inadvertently chooses the wrong one. In the hospital
where the error took place, Neumega is being added to the
pharmacy computer, along with some electronic warnings to
check the patient's lab values to make sure it is Neumega
that is ordered and not Neupogen. Additionally, continuing
education is being planned for drugs used in oncology so that
all the staff can become more familiar with these complex
agents. Physicians prescribing either drug would be wise to
include "for platelets" or "for white cells" within the order.
This further reduces the likelihood of a mix-up between these
two important human growth factors.