Hospital Pharmacy - June 2017 - 392

392

Hospital Pharmacy 52(6)

premixed solutions. Hospital staff often scan the barcode on
heparin bags when restocking automated dispensing cabinets
to ensure that the bags are placed in the correct stock location. The barcode that identifies the product is printed above
the barcode for the lot and expiration date but behind a
crimped seam on the clear overwrap (Figure 1), making it
difficult or impossible to scan the barcode without removing
the bag from the overwrap. Removing a bag from its overwrap affects how long the bag can be stored and is not recommended until right before use.
This situation eliminates the possibility of an important
safety practice with this high-alert medication-barcode
scanning. If the crimped seam was over the back of the bag,
there would be no problem scanning it. No errors have been
reported, but there is an opportunity for mix-ups if the pharmacy must work around the problem and apply a barcode
label to the bag. B. Braun told us that they are aware of this
problem and are working to correct the situation.

Warning! Inconsistent Expression of
Strength on Outsourced Anesthesia
Syringes
Not all outsourcing companies that dispense prefilled
anesthesia medication syringes label their products in the
same way. This may lead to dangerous confusion when
switching from one company to another, or when practitioners work in several different hospitals or ambulatory
sites. Unlike with commercial manufacturers that provide
sterile injectables, the FDA has not been holding outsourcers that perform sterile compounding to any standard for
labeling their syringes. Per US Pharmacopeial Convention
(USP) <7>, which commercial drug manufacturers must
follow, the strength per total volume should be the primary
and prominent expression on the principal display panel of
the label, followed in close proximity by strength/mL
enclosed by parentheses.
A compounded product from Cantrell Drug Company (red
and black labeling at top in Figure 2) correctly lists the concentration per the USP requirement for strength per total volume as the primary and prominent expression (200 mg/10
mL). This is followed by the amount per mL, printed immediately below and less prominently (20 mg/mL). The
PharMEDium syringe (at bottom in Figure 2) lists the strength
in an opposite way, with the amount per mL as the prominent
display (20 mg per mL). Both syringes are the same strength
and hold exactly the same amount of drug.
A pharmacist and anesthesiologist reported that they
found both types of syringes in the same pocket of the anesthesia cart in the operating room suite, which they thought
could lead to a significant medication error if the strength
was misidentified. Apparently, syringes from each outsourcer
had been purchased without realizing the difference in the
labeling.

Figure 1. Location of seam on the protective overwrap of B.
Braun heparin premixed solutions.
Note. Color figure is available in the online version of this article.

Figure 2. Differences in labeling of compounded products.
Note. Color figure is available in the online version of this article.

The PharMEDium strength presentation, where 20
mg/mL is most prominent, can be confusing to a practitioner
who is more familiar with all other commercial vials and prefilled syringes that list the amount per container most prominently (eg, 200 mg per 10 mL). Other outsourced syringes of
anesthesia medications may also use this unsafe format.
Evidently, this format is used at the request of anesthesiologists who administer medications IV based on the amount
per mL listing.

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