The Institute for Safe Medication Practices has received numerous reports on the dispensing of unmixed oral suspensions, in particular unmixed antibiotics, to patients. Most cases have involved pediatric patients who received antibiotic overdose when their parents administered the drug powder without mixing the children. The community pharmacies involved had not mixed the antibiotics before dispensing them.
In one case, a pharmacy dispensed unmixed amoxicillin powder for a child. The child’s father measured and administered 9 ml of the powder before realizing that it was unusual not to have received a liquid medication. The child was determined to ingest 9 g of unmixed amoxicillin powder instead of 450 mg of the mixed suspension.
In another case, an 8-month-old girl was prescribed suspension of amoxicillin / potassium clavulanate to treat an ear infection. The prescription was taken to the local community pharmacy, which distributed a bottle of common medication labeled with instructions to give the child a half teaspoon twice a day orally. When the family arrived home, they measured a half teaspoon of powder and administered it to the girl. The girl was rushed to the emergency department, where she was treated for an overdose of antibiotics.
More recently, one pharmacist reported that azithromycin 100 mg / 5 ml for oral suspension was prepared by a pharmacy technician who placed the pharmacy label on the outer carton. The pharmacist who reviewed the prepared recipe did not open the box to look at the bottle itself or check that the medication had been reconstituted. Fortunately, in this case, the mother made a mistake when she got home and returned the product to the pharmacy before giving any medication to her son.
Dispensing an unmixed drug is a mistake that should never occur if you have several strategies in place. Evaluate the safeguards you currently have in place and consider the following risk reduction strategies:
- Add a note or label to the prescription receipt stating that the product needs to be mixed prior to dispensing. One suggestion we have received is to place these products in a clear plastic bag with a label stating “NEED TO MIX” stapled to the outside of the paper bag. Another possible process is to place the pharmacy receipt, stapled on a brightly colored card labeled “NEEDS TO BE MIXED”, in a clear plastic bag, but without the medicine container.
- Place the actual product container that requires mixing in a separate area. After the product is reconstituted, the product should be given to the pharmacist, along with any other prescription, to advise the patient on how to measure the medication.
- Include specific product descriptions on the prescription label (eg, orange, white, opaque flavored liquid) that will indicate that it is an oral, liquid product.
- At the point of sale, open the bag and check the label, route of administration, storage requirements and instructions for use with the patient. Shake the bottle to show how to mix the suspension before administration. Open the bottle with the patient and / or caregiver to check the contents.
- Investigate ways to take advantage of point-of-sale technology to alert staff to check that prescription medicines that require reconstitution have been mixed.
- Make sure that oral syringes or other appropriate measuring devices, which correspond to the instructions on the label, are supplied with the product.
- Provide education to patients and caregivers on the proper use and cleanliness of the measuring device.
- To validate learning, have the caregiver or patient demonstrate how to measure and administer the dose.
- Review, with all your staff, what strategies you have to avoid this mistake.