SIMILAR-SOUNDING NAMES
Droperidol or dronabinol?
A pharmacist received a call from a physician assistant (PA) requesting help prescribing a medication for a patient with nausea and vomiting. The PA told the pharmacist that he was looking for dronabinol in the electronic health record drug dictionary but could not find it. The pharmacist clarified the brand name (Marinol) and the generic name (dronabinol) as well as the indication (nausea and vomiting). Finally, the pharmacist asked what dose was needed, to which the PA replied, "5 mg." It was not discovered until later that the PA had actually been looking for droperidol (formerly available as Inapsine), not dronabinol, to treat this patient.
Dronabinol is a synthetic oral cannabinoid provided in capsules (2.5, 5, and 10 mg strengths) and as an oral solution (5 mg/mL). In contrast, droperidol is an antipsychotic that helps reduce nausea and vomiting by blocking dopamine stimulation in the chemoreceptor trigger zone. It is available as a solution for injection (2.5 mg/mL).
A dose of 5 mg is a reasonable starting dose for both medications. This likely contributed to confirmation bias, making both the PA and pharmacist believe they were talking about the correct drug. Unfortunately, neither the pharmacist nor the PA clarified the intended route of administration, and the PA did not recognize the discrepancy when the pharmacist specified the brand name, Marinol.
During verbal communication of medication prescriptions, speak clearly and always follow through with readback to ensure accurate communication. Spell out sound-alike drug names when reading back a verbal order. Clinicians should specify all portions of the medication order when prescribing and during readback (patient's name and identifiers, drug name, strength, dose, dosage form, indication, frequency, route, provider).
In this case, if either party had clarified the administration route, the mix-up would probably have been caught earlier. The Institute for Safe Medication Practices (ISMP) is considering the use of tall man lettering for these two drugs because they look very similar and plans to update its tall man letter list this year.
MEDICATION SAFETY
Protect pets as well as children
The topical chemotherapeutic drug fluorouracil, often used to treat skin disorders such as actinic keratosis or basal cell carcinomas, is extremely toxic to dogs and cats. Mortality for these pets is high following ingestion of even small amounts of fluorouracil. Exposure often happens when a pet licks the owner's skin where the medication was applied or chews the fluorouracil container.
Clinical signs and symptoms such as altered mentation, tremors, ataxia, and seizures develop rapidly. No reversal agent is available for pets and treatment options are generally palliative.
Product labels on fluorouracil do not alert or educate users about this risk. ISMP has asked major information vendors to prominently include this information in patient instructions, and the FDA has posted more information about the problem at http://www.ismp.org/ext/600.
IN-LINE FILTERS
New recommendations from ASPEN
The American Society for Parenteral and Enteral Nutrition (ASPEN) has published a position paper on the appropriate use of in-line filters during parenteral nutrition (PN) administration. The recommendations serve as an update to previously published recommendations. Based on best available evidence and guidance from scientific and regulatory agencies, ASPEN recommends using a 1.2 micron in-line filter for administration of total nutrient admixtures, dextrose-amino acids admixtures, and lipid injectable emulsions. Using a single 1.2-micron filter for PN administration alleviates the confusion associated with using two separate filters with different pore sizes. Read the position paper at http://www.ismp.org/ext/586.