Rotarix cap choking hazard
The new, ready-to-administer Rotarix (rotavirus vaccine, live, oral) dosing applicator formulation by GSK (http://www.ismp.org/ext/1032) will soon be available. It previously required reconstitution. The dosing applicator tip cap could present a choking hazard if used improperly (see The new Rotarix [GSK] prefilled oral dosing applicator and tip cap). The clinician administers the vaccine by placing the oral dosing applicator, which looks like a prefilled syringe, into the infant's mouth. Clinicians must remove a protective cap on the tip of the syringe before administration, as emphasized by the GSK labeling (see Remove and discard the Rotarix oral dosing applicator tip cap prior to administration). Leaving the empty dosing applicator or the removed tip cap within reach of a baby or child, such as on an examination table, is a choking hazard.
The ISMP is unaware of any such reports with the Rotarix vaccine, but one cannot be too cautious. Years ago, there were cases of asphyxiation after practitioners provided parents with parenteral syringes, which at the time had a tip cap to measure their child's oral liquid antibiotic dose. Unfortunately, not all parents realized they had to remove the syringe cap before using it. The cap was often loose enough so the person preparing the dose could draw the oral liquid into the syringe without removing it. Then, when they placed the syringe tip into their child's mouth to administer the medication, the cap fell into the child's mouth.
As a result, BD eliminated caps from all parenteral syringes. Rotarix is available in a squeezable tube in some countries, including Canada. The manufacturer told the ISMP that the decision to use the oral applicator presentation in the US was based on clinician market research, which showed a clear preference for the oral applicator rather than a squeezable tube due to the ease of delivery and controlled administration.
Etoposide vial found in DOXOrubicin carton
The ISMP National Medication Errors Reporting Program recently received a report about a potential packaging error involving certain chemotherapy products. The outer carton identified the vial inside as "DOXOrubicin 20 mg/10 mL," but the vial contained inside the carton was labeled "etoposide 100 mg/ 5 mL." The reporting organization does not typically purchase this strength of etoposide.
Although the cartons are not individually sealed, the pharmacist noted that the carton appeared to be unopened. So, it was uncertain if the package was tampered with, if the mistake was due to a manufacturer packaging problem, or if someone on staff repackaged the product incorrectly. The manufacturer completed an investigation of this situation and did not find any evidence of error on their end.