1. Shastay, Ann MSN, RN, AOCN

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An ELIQUIS (apixaban) starter pack was prescribed for a patient who was starting treatment. The starter pack indicates that two 5 mg tablets (10 mg) should be taken twice daily for 7 days, followed by one 5 mg tablet twice daily, for treatment of deep vein thrombosis and pulmonary embolism. Although the default setting in the electronic prescribing system for the starter pack was zero refills, this field was modified by a provider, and the prescription was sent to a pharmacy with refills. The outpatient pharmacy did not catch the error, and several months of refills were dispensed. Thankfully, the patient did not follow the directions on the starter pack each time it was refilled and was taking just one 5 mg tablet twice daily, as intended. Upon further investigation, the reporting institution found additional errors in which the starter pack had been prescribed with refills. In each of these prior instances, the dispensing pharmacy caught the error and corrected the prescription.


Provide patient education about starter packs to explain why it is being prescribed, that the pack is only to be used for the beginning of therapy and should not be refilled, as well as the appropriate maintenance dosing following the starter pack. If both prescriptions, one for the starter pack and one for the maintenance dose following initial therapy, are sent together to the dispensing pharmacy, the prescriber should instruct the pharmacist to put the maintenance dose prescription on hold until the starter pack has been completed. The patient should be instructed to complete the starter pack first, and the statement, "Begin taking only after the starter pack has been completed" should be included in the maintenance dose directions. We have received other reports of errors where patients mistakenly took both the starter dose and maintenance dose of rivaroxaban concurrently when both prescriptions were sent to a pharmacy without clear instructions.


Outpatient Antibiotic Prescriptions for Older Patients

Antibiotic misuse, overuse, and resistance have been identified as significant public health risks. Antibiotic overuse can lead to adverse effects (e.g., Clostridium difficile infection), especially in older adults. A Centers for Disease Control and Prevention (CDC) study, published in the Journal of the American Geriatrics Society, found that, in the outpatient setting, patients over age 65 are prescribed antibiotics at the highest rate of any age group (Kabbani et al., 2018). Using data on outpatient antibiotic prescriptions dispensed for older adults from 2011 to 2014, CDC identified that in 2014, older adults were prescribed and dispensed 51.6 million antibiotic prescriptions. Also, patients 75 years and older had a higher rate of antibiotic prescriptions than those aged 65 to 74 years. Although antibiotic prescriptions for older adults leveled off over the study period, on average, adults aged 65 and older received enough outpatient antibiotic courses for every older adult to receive at least one. The authors also evaluated the prescribing rates by antibiotic and provider specialty. The most commonly prescribed class was the quinolones. Azithromycin was the most commonly prescribed drug. Family practice and internal medicine providers prescribed 43% of all antibiotics for older adults.


In 2016, CDC published its Core Elements of Outpatient Antibiotic Stewardship ( The Core Elements provide a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. CDC also has resources ( for community pharmacists to help them and their patients be active agents in antibiotic stewardship.


TraMADol-TraZODone Mix-Ups

As evidenced by the length of the ISMP List of Confused Drug Names (, we have received many reports of potential and actual drug mix-ups. One of the more frequently reported confused drug name pairs is traMADol and traZODone. These drug names look much too similar and set healthcare practitioners and patients up for errors. The problem is worsened because both drugs are available in 50 mg strengths. When the same manufacturer packages both drugs, the containers may look alike, and these look-alike containers are often stored alphabetically and therefore end up next to one another on the pharmacy shelf. Plus, many pharmacy computer systems allow drug searches using only the first 3 characters of a drug name. In this case, both drug names start with "tra" meaning both traMADol and traZODone will appear together when "tra" is used as the search term. When performing medication reconciliation for patients prescribed traMADol or traZODone, carefully examine the name of the drug dispensed to the patient.


Question Builder App Helps Maximize Benefit of Doctor's Visits

The Agency for Healthcare Research and Quality has released a mobile app to help consumers make their doctor's office visits more efficient. The free Question Builder app ( helps consumers prepare and organize information and questions for their doctor ahead of time and puts that information at their fingertips during office visits. The Question Builder app has a host of other helpful features. For instance, consumers can snap a photograph of things like a pill bottle or a skin rash to show the doctor.


Never Underestimate the Need for Patient Education

As a result of known situations where a single insulin pen was used for multiple patients, the Food and Drug Administration required pen manufacturers to include a statement, "For single patient use only," on all pens and outer cartons. The statement seems cut and dry. However, a patient who was newly started on NOVOLOG Mix 70/30 (insulin aspart protamine and insulin aspart) thought "single patient use" meant to administer the entire contents at once. The patient had not received any education about administration technique or dosing. It is unknown if the patient received 60 units (the maximum that can be dialed as a single dose) or the entire 300 units in the pen. The patient became unresponsive and was brought to the hospital with a blood glucose level below 30 mg/dL. The patient was placed on a 10% dextrose infusion and became responsive. When educating patients about the use of insulin pens, be sure to discuss the meaning of "For single patient use only."




Kabbani S., Palms D., Bartoces M., Stone N., Hicks L. A. (2018). Outpatient antibiotic prescribing for older adults in the United States: 2011 to 2014. Journal of the American Geriatrics Society, 66(10), 1998-2002. [Context Link]