Hospital Pharmacy - July/August 2018 - 217

771814
research-article2018

HPXXXX10.1177/0018578718771814Hospital PharmacyCohen and Smetzer

ISMP Medication Error Report Analysis

Hospital Pharmacy
2018, Vol. 53(4) 217-219
© The Author(s) 2018
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https://doi.org/10.1177/0018578718771814
DOI: 10.1177/0018578718771814
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Michael R. Cohen1 and Judy L. Smetzer1

CycloSPORINE Dispensing Errors
Almost 20 years ago (ISMP Medication Safety Alert!
September 9, 1998), we published an article about
SANDIMMUNE (cycloSPORINE capsules and oral solution) and how this nonmodified form of the drug has
decreased bioavailability compared with NEORAL or
GENGRAF (cycloSPORINE [MODIFIED] capsules and
oral solution). At the time, a survey by Novartis identified
that 24% of prescriptions failed to specify which form of the
drug should be dispensed, and only 22% of these prescriptions were clarified. We mention this because, 20 years later,
we are still receiving reports of patients receiving
SandIMMUNE when the prescriber's preference was for a
cycloSPORINE-modified oral formulation. Three patients
recently received SandIMMUNE instead of the more appropriate form of the drug, Neoral or Gengraf. In another case,
during medication reconciliation, a nurse documented that a
hospitalized patient was taking cycloSPORINE but did not
verify the brand name to determine whether it was the modified or regular form of the drug. The patient's physician prescribed SandIMMUNE, and the patient received a dose
before a pharmacy technician discovered that the patient had
recently filled a prescription for Gengraf.
Because of the difference in formulation, these products
are not interchangeable. Blood levels must be monitored to
prevent serious consequences if a transplant patient receives
the wrong formulation. Prescribers should indicate the brand
name, and pharmacists should clarify prescriptions for cycloSPORINE. Order entry systems should clearly display these
different forms of the drug, and a hard stop should force verification of the correct drug form during prescribing.

CycloSPORINE Oral Solution Error
A 10-fold overdose of modified cycloSPORINE oral solution (100 mg/mL) was administered to a child. The physician
prescribed 0.5 mL (50 mg), and the pharmacy dispensed a
sealed package of the medication (100 mg/mL), which contained a 5 mL oral syringe (Figure 1) provided by the manufacturer, AbbVie, that was calibrated in 1 mL increments,
with hash marks between each mL. The child's parent gave 5
mL (500 mg) instead of 0.5 mL to the child for several days.
Patients who received solid organ transplant or allogeneic
hematopoietic stem cell transplants are required to take

long-term immunosuppressant drugs to prevent rejection and
graft-vs-host disease. The dosages of immunosuppressants
are usually individualized based on the type of transplant,
target blood level, body weight, drug-drug interactions, and
the risk of rejection or toxicity. Many transplant centers use
oral solution formulations of immunosuppressant agents to
allow greater flexibility in dosage adjustments, especially for
pediatric patients. As immunosuppressant agents have significant interpatient dosing variability, dosage delivery
devices need to be selected specifically for each patient, and
one size does not fit all. In this case, the 5 mL syringe size
was significantly larger than each intended dose and did not
facilitate accurate measurement and delivery of the prescribed dose.
Upon product dispensing, pharmacists should evaluate
the appropriateness of the dosage delivery devices included
in the package. A 2016 study1 found that parents made fewer
errors when measuring oral liquid medications for their children with oral syringes compared with dosing cups. However,
the error rate with using oral syringes was still 16.7%. The
researchers also found that providing dosing devices that
closely matched the prescribed volume per dose offered the
greatest reduction of errors.2 Health care professionals
should ask patients/caregivers to show them how they will
properly measure oral liquid medications using their dosage
delivery device. (If the pharmacy that dispensed the cycloSPORINE had done this, the dosing error might have been
avoided.) The manufacturer and the US Food and Drug
Administration (FDA) were notified about this event, and a
recommendation was made to investigate including a smaller
syringe for pediatric patients in the package.

Patients Should Not Swallow AcipHex
Sprinkle Capsules!
ACIPHEX SPRINKLE (RABEprazole sodium) delayedrelease capsules are used to treat gastroesophageal reflux
disease in children 1 to 11 years for up to 12 weeks.
1

Institute for Safe Medication Practices, Horsham, PA, USA

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

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