Gabapentin Dispensing errors -- be careful!!
- From: "rose" <rosedawn_scott@xxxxxxxxx>
- Date: 15 Feb 2006 05:05:51 -0800
this is more directed at pharmacists than at patients, BUT, it's got a
special resonance for me, because this happened to me once. i was
filling a script for generic Tegretol -- carba-whatever -- and when i
got the bottle hom, i noticed the pills looked *really* different. i
wasn't sure if they'd changed the look, or if the pills were from a
different manufacturer, which is why they looked different...so i read
he package inserts. turns out, they'd made a mistake and dispensed
something else that started with car-, an organ transplant rejection
drug, major immune-suppressant. yes, i know some of us do take that tpe
of medication -- but not when you're *supposed* to be taking Tegretol!
you *can't* abswolutely count on your pharmacist -- or your
pharmacist's staff -- to be properly cautious, so just a heads-up
reminder: LOOK at your meds, and READ the package insert. it's always a
good idea anyway, but when it comes to a possible dispensing error, it
actually *could* save your life.
---------------
Gabapentin Gemfibrozil Look-Alike Packaging
Posted 02/09/2006
A community pharmacist recently refilled a prescription for a patient
who had been taking 6 gabapentin 600 mg tablets daily. However, due to
limited inventory, a partial refill was dispensed. Later, when the
balance was being prepared, a 60 tablet stock bottle of the
antihyperlipidemic agent gemfibrozil 600 mg was incorrectly selected
and dispensed to the patient. When the patient returned with her
bottles for a refill, a technician recognized the error. The patient
was notified and subsequently evaluated in an emergency department.
Fortunately, all tests were within normal limits; however, as a result
of poorly controlled neuropathy, the patient didn't feel well for
several weeks. In another report, a prescription bottle was filled with
both gabapentin 600 mg and gemfibrozil 600 mg tablets after a bottle of
gemfibrozil was mistakenly stored with gabapentin 600 mg bottles.
However, upon visual inspection of the final product, pharmacist
noticed the subtle differences in tablet appearance and corrected the
error.
Multiple similarities contributed this error. The stock bottles were
the same size and from the same manufacturer, contributing to the
similar packaging and labeling (see photo). Also, each name begins with
the letter "G," the names are similar in length, each is available as a
600 mg tablet, and the medications were stored alphabetically by
generic name, placing gabapentin and gemfibrozil just one shelf apart.
The patient who received gemfibrozil in error didn't notice a change in
tablet appearance because both were similar in size, shape, and color.
One reporter noted that these medications were commonly misplaced in
one another's spot on pharmacy shelves. This pharmacy has since
relocated gemfibrozil to another area of the pharmacy to help prevent
future mix-ups.
ISMP contacted Teva Pharmaceuticals USA to recommend that they
differentiate the product labeling for these drugs. Teva stated that
they recently updated the product labeling of gemfibrozil. At that
time, they also decided to change the color on the package label to
purple to help to avoid confusion between these two products. However,
the updated packaging may not have yet reached all wholesalers.
Take proactive steps to prevent similar errors in your practice by
discouraging staff from relying solely on visual cues on packaging
(color, layout, manufacturer styling) when stocking or returning
medications to pharmacy shelves. As shown in the example above, if one
look-alike item is inadvertently misplaced in the space usually
reserved for another, it makes it more likely that the wrong product
will later be selected for dispensing. When products are routinely
found misplaced on the shelf, staff should consider why, discuss the
potential for error and patient harm, and develop preventive measures.
--------------
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