Lacosamide labels need improvement
Unit-dose cups of VistaPharm's lacosamide oral solution, an antiepileptic drug, are each labeled 10 mg/mL, even though there are four different dosages available, 50 mg (5 mL), 100 mg (10 mL), 150 mg (15 mL), and 200 mg (20 mL) (see Lacosamide unit-dose cups). Labeling each unit-dose cup as 10 mg/mL could lead to misidentification of the total amount of drug in the cup. Each cup may be mistaken to contain only 10 mg of the drug. Although the label mentions the volume that each cup delivers, that information is separated from the concentration and may be missed. Unfortunately, no labeling standard requires the total dose to be expressed on each oral liquid unit-dose cup. ISMP has contacted the US FDA to look into this. If your facility purchases multiple strengths of the cups, clearly distinguish the products and use bar code scanning technology before dispensing and administration.
Bar code needed for BluePoint enoxaparin blister package label
A bar code is not present on the outer unit-dose blister package label of enoxaparin syringes, a low-molecular-weight heparin, manufactured by Amphastar Pharmaceuticals for BluePoint Laboratories. This makes it impossible to use bar code scanning for product verification and pharmacy inventory management without removing the syringe from the blister package to scan the bar code on the syringe barrel. Otherwise, the national drug code must be manually entered into the pharmacy computer system to confirm the product.
BluePoint is modifying the package, but some products under the previous labeling are still circulating.
Look-alike NexJect syringes
NEXJECT prefilled syringes are designed for tamper-resistant, efficient, and convenient medication delivery. They are available for certain products in short supply such as injectable opioids including HYDROmorphone and morphine. When stored in an automated dispensing cabinet (ADC), NexJect syringes can roll, making it difficult to see the drug names when the syringes are being restocked or retrieved, and exposing label similarities.
A nurse removed what she thought were two syringes of morphine 2 mg/mL from the ADC compartment for this product. When scanning the syringes at the bedside, the nurse identified that one was actually HYDROmorphone 1 mg/mL. Fortunately, the wrong medication did not reach the patient.
The error occurred when restocking both morphine and HYDROmorphone syringes in the ADC. Not all of the syringes were scanned when they were loaded into the ADC, as policy required.
On the NexJect syringes, the morphine 2 mg/mL strength is printed on a white background. The HYDROmorphone 1 mg/mL strength is printed on an orange background (see NexJect primary display panels). However, both syringes have identical green and black tamper markings visible from all perspectives, making these syringes look very similar (see Look-alike view).
Bar code scanning is critical, as is reading the actual syringe label. Pfizer has been contacted regarding this safety concern.