Tragic Events with Concentrated Opiate Oral Solutions

(November 2008) An alert from the Institute for Safe Medication Practices warns about potentially fatal errors that can occur with concentrated oral opiate solutions.

ISMP cites a recent case involving an 18 year old who was prescribed oxycodone oral solution to treat throat pain associated with strep throat. He mistakenly received a 100 mg dose of concentrated oxycodone solution instead of the prescribed 5 mg. He suffered organ failure, went into a coma, and required mechanical ventilation.

It is not certain how this event occurred, but ISMP points out several factors that have contributed to these kinds of errors in the past. In some cases, concentrated oral liquid opiates have been confused with conventional concentrations. This may be more likely to happen when concentrated products are stored near the conventional ones on pharmacy shelves. Also, some physicians prescribe oral liquid medications in milliliters instead of milligrams, which presents problems when a product is available in multiple concentrations.

ISMP recommends several ways to reduce the chance of these kinds of errors. Here are some of them:

•When appropriate, consider non-opiate medications and non-drug therapies for pain relief, especially for less severe pain.

•Reserve concentrated solutions for patients who either need higher than usual doses because of severe chronic pain, or who can't swallow larger volumes of liquid.

•Always prescribe and dispense liquid medications with the dose specified in milligrams.

•Build alerts into computer order entry systems to warn about potential mix-ups between various concentrations of oral opiate solutions.

•Consider adding the word "concentrated" immediately after the drug name on computer screens to better differentiate concentrated products from other concentrations.

•Use barcode scanning to verify that the right product was selected. When the concentrated formulation is scanned, a hard stop alert should require pharmacist documentation.

•Purchase and dispense concentrated solutions in dropper bottles. This can help prevent dose-measurement errors and to differentiate the concentrated solution from other non-concentrated strength solutions.

• And finally, counsel all patients or their caregivers about how to use oral opiate solutions safely. To check their understanding, have them repeat back this information and demonstrate how to measure the dose. Advise them to question any change in product appearance, because this could signal an error in prescribing or dispensing the drug.

Category:

Science & Technology

Tags:

• Concentrated
• Opiate
• Oral
• Solutions
• Fatal
• Oxycodone
• FDA
• Patient
• Safety

[Shurupadi]

Boo how in the hell ??

[jdubz5501]

yo it is important that people get pain relief when they need once some 1 is dependent to opiates it is harder then hell to quit cold turkey so they are doing what there body is telling them to do if they dont get that fix it is the worst flu symptoms tymes 10

[helraiser666painkil]

that is awrful I am getting help from my doctor at this very moment I'm on subutex because of a doctor this man gave me morphine pills and I got hooked on them all the doctors around the world need to stop giveing high dose codine dihydrocodiene morphine tylex solphadol tramerset tramadol vicadin to people out there unless you really need it and are in pain otherwise prescribe something non opiate that is why so many people die and are addicted to opiates it needs to stop NOW PLEASE!!!!!!!!!!!!