Errors Associated with Paxlovid

Paxlovid was authorized under the emergency use authorization (EUA) by the US Food and Drug Administration (FDA) in December 2021 and is used for mild-to-moderate coronavirus 2019 (COVID-19)  in adults and pediatric patients (12 years and older weighing at least 40 kg) who are COVID-19 positive and at risk of progressing to severe COVID-19, including hospitalization or death. Since its introduction, ISMP and the FDA have received numerous reports of wrong dose errors related to Paxlovid.

In this podcast, we discuss the indications for use of Paxlovid, as well as dosing errors that have occurred throughout the medication-use process. These errors include prescribing or dispensing the wrong strength, improper renal dosing, and self-administration errors. The discussion also includes recommendations from ISMP to prevent these types of errors and patient harm.


Nikhila Viswanathan, PharmD, MS, Regulatory Pharmaceutical Fellow in Medication Safety, Novartis, Name Creation & Regulatory Strategy

Sadik Owolewa, PharmD, 2022-2023 FDA/ISMP Fellow, Institute for Safe Medication Practices

This podcast is supported by Novartis, Name Creation & Regulatory Strategy.