Hospital Pharmacy - April 2018 - 90

747449
research-article2017

HPXXXX10.1177/0018578717747449Hospital PharmacyCohen

ISMP Medication Error Report Analysis

Hospital Pharmacy
2018, Vol. 53(2) 90-92
© The Author(s) 2017
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https://doi.org/10.1177/0018578717747449
DOI: 10.1177/0018578717747449
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Michael R. Cohen1

Dispense a Needle With That Pen

Med Wreck?

A diabetic patient visited an endocrinologist at an academic medical center, where she was prescribed Humulin
R (insulin regular concentrate) U-500 pens. The patient
was to administer 140 units 3 times a day. The prescription
was dispensed by the medical center's ambulatory pharmacy, where the patient was given the pens but no pen
needles. Since she didn't have any needles for the pens,
when she got home she used one of her U-100 syringes that
she had used with her previous U-100 insulin to draw her
insulin dose from the U-500 insulin pen cartridge (essentially using the pen as a vial). It's possible that she may
have measured and administered as much as "140" units
(700 units of U-500). Her daughter found her unresponsive
and called for an ambulance. When emergency medical
technicians arrived, they gave the patient 12.5 g of 50%
dextrose and transported her to the hospital, where she
fully recovered.
In a similar situation, a patient was previously using insulin glargine U-100 but switched to Toujeo (insulin glargine
U-300). In this case, he was given pen needles to use with
Toujeo, but at home, he decided to use up the remaining supply of U-100 syringes. Using the insulin pen cartridge as a
vial, he drew up a dose, filling the U-100 syringe to the 100
unit mark-the same daily Lantus dose (100 units) he had
been taking. This resulted in a dose of 300 units of Toujeo,
not the prescribed 100 units, which led to hypoglycemia
requiring hospital admission.
Plans are underway at the medical center where the
most recent error was reported to give pharmacists authority to dispense pen needles without a prescription whenever insulin pens are prescribed. Perhaps insurance
providers that currently require a prescription for needles
should take note and allow pharmacists to dispense appropriate pen needles whenever a pen device has been prescribed. Also, it is critical for prescribers, nurses, and
pharmacists to educate patients about the proper use of
insulin pen devices, the importance of using the correct
pen needle with the device, and to never use the insulin pen
cartridge as a vial. In addition, a process should be in place
prior to discharge to ensure that patients have the medications or prescriptions, equipment, and supplies needed at
home to manage their insulin therapy (e.g., insulin,
syringes or pen needles, blood glucose meter and strips,
lancets, lancing device, glucagon emergency kit).

A patient with atrial fibrillation (nonvalvular) was admitted
to a hospital for insertion of a left atrial appendage device
used to prevent stroke in patients who are not good candidates for long-term anticoagulation. When preparing the
patient's list of home medications, hospital staff entered
VESIcare (solifenacin) instead of the intended product,
Vessel Care, a nutritional supplement the patient was taking.
VESIcare is used to treat overactive bladder with symptoms
of incontinence, urgency, and frequency. However, the
patient did not have this condition.
Because the error was not recognized, the order was converted to oxybutynin based upon the hospital's therapeutic
formulary interchange for VESIcare. A dose of 5 mg every
12 hours was ordered, which the patient received postoperatively. The patient developed urinary retention that required
urinary catheterization, although it's unclear whether anesthetics given during the procedure may have also caused or
contributed to the problem. The error was finally discovered
by a pharmacist reviewing the patient's medication list during transition-of-care rounding prior to discharge.
The reporter commented that a more robust medication
reconciliation process was needed. Prescribers do not
always reconcile the medication list with the patient's indications or review the home medication list with the patient,
especially if the patient was admitted for an elective procedure. While a home medication list is initially compiled by
nurses, the actual reconciliation process is often incomplete.
One suggestion would be to have a pharmacy staff member
collect and verify the medication history, and then confirm
that the prescriber has reviewed and reconciled the list (if
the appropriate resources for such a pharmacy service are
available). Also, prescribers, pharmacists, and nurses should
attempt to verify that any drug prescribed, dispensed, or
administered is indicated for the patient based on his or her
medical conditions.
We notified the US Food and Drug Administration (FDA)
as well as Astellas, which distributes VESIcare in the United
States, about the look- and sound-alike name confusion.
1

Institute for Safe Medication Practices, Horsham, PA, USA

Corresponding Author:
Michael R. Cohen, President, Institute for Safe Medication Practices, 200
Lakeside Drive, Suite 200, Horsham, PA 19044, USA.
Email: mcohen@ismp.org

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