Hospital Pharmacy - June 2018 - 145

145

Cohen and Smetzer

Educate Prior to Discharge

Please, No More Teaspoon Dosing

Educate patients regarding the directions for taking the correct dose of tacrolimus, how to manage dose changes, and
the importance of monitoring drug levels. Ensure that
patients can repeat back the specific directions for taking
each prescribed dose. Provide patients with information
about the common types of errors that may happen with
tacrolimus and how to prevent and detect these errors.

Some community or ambulatory care pharmacists mistakenly believe it is helpful to "translate" prescription liquid
dosing instructions for patients from metric (eg, milliliters
[mL]) to household measures (eg, teaspoon). When they
receive a prescription with dosing in mL, they change it to
teaspoon dosing or list both teaspoons and mL (in parentheses) on the label, believing most consumers are more familiar with household measures than metric dosing.
Unfortunately, pharmacy staff have inadvertently typed
the number of mL in the teaspoons field, sometimes resulting
in patient hospitalization. A close call occurred recently when
AUGMENTIN ES-600 (amoxicillin and clavulanate) suspension was prescribed for a child with otitis media. When
the child's mother picked up the medication, a pharmacist
provided counseling about how often to give each dose, to
discard the medication in 10 days, and that it may cause diarrhea. However, the actual volume required for each dose was
not discussed. Later, when the child's parent read the label at
home, it said, "Give 5 teaspoons by mouth twice daily for 10
days." Wondering if this was accurate, she logged into an
electronic patient portal to view a summary of her child's
office visit and saw that the dose should have been 5 mL, not
5 teaspoons.
Mix-ups between mL and teaspoon have been a longstanding problem, first discussed by ISMP in this publication in 2000. In recent years, there has been considerable
movement toward the use of the metric system for all overthe-counter (OTC) and prescription liquid medications.
Most oral dosing devices now display a mL scale, some
exclusively. Thus, "translating" mL doses to teaspoons, or
listing both teaspoons and mL on labels, should cease, as it
is not helpful to patients and creates confusion. The National
Council for Prescription Drug Programs (NCPDP) published Recommendations and Guidance for Standardizing
the Dosing Designations on Prescription Container Labels
of Oral Liquid Medications in 2014, calling upon stakeholders, particularly pharmacy leadership, to adopt mL dosing as
the standard (https://www.ncpdp.org/NCPDP/media/pdf/
wp/DosingDesignations-OralLiquid-MedicationLabels.
pdf). This is needed for all patient instructions on pharmacy
labels and in computer systems. Also, always provide an
appropriate metric dosing device and ensure that patients or
caregivers know how to measure the dose in mL, using
"teach back" to confirm understanding.

Conduct Outpatient Counseling
Establish a fail-safe mechanism to ensure that patients are
counseled when picking up prescriptions for tacrolimus, particularly for the first prescription and whenever the dose,
dosage strength, or formulation is changed.

Recommendations for FDA and Drug Companies
We call upon FDA and drug companies to avoid the availability of doses in 10-fold increments whenever possible. We
also call upon the manufacturer of Astagraf XL (Astellas)
and FDA to evaluate whether labeling changes are necessary
given consumer confusion with the term "ONCE-DAILY."
ISMP thanks Staley Lawes, PharmD, BCPS, FISMP, for
her contribution to this article.

Ensuring Safety of Recipes for Drug
Compounding
During a biannual update of drug compounding recipes, one
of the pharmacy's recipes for a cloNIDine formulation was
updated incorrectly. Based on information found on an online
pharmacy help site, the hospital's recipe for preparing a
cloNIDine suspension was updated. The new recipe was
intended to prepare a 0.1 mg/mL suspension; however, the
directions from the previous recipe were left in place accidentally, which correlated with a 0.01 mg/mL concentration.
Thus, the final concentration using the updated recipe would
be 10-fold lower than the recipe indicated.
The recipe change was made by a pharmacist without an
independent double check, which was the pharmacist's usual
practice but not a required element of the recipe updating process. The error led to administering a 10-fold underdose to an
infant in a neonatal intensive care unit.
Errors made in drug compounding recipes can affect multiple patients, so it is important to always have a second individual perform an independent double check of all the information
in listed recipes. The pharmacy has now instituted this as a
required practice to ensure that all parts of the recipes match,
including the concentration it yields. Fortunately, only one
patient received the incorrectly prepared suspension after the
recipe error was made. Based on a chart review, a pharmacist's
consult note, and follow-up after 4 months, there was no apparent harm from the underdosing that occurred with this patient.

References
1.

Han J, Beeton A, Long PF, Wong I, Tuleu C. Physical and microbiological stability of an extemporaneous tacrolimus suspension
for paediatric use. J Clin Pharm Ther. 2006;31(2):167-172.
Michigan Pediatric Safety Collaboration. Tacrolimus suspension.
In: Michigan Collaborative Standardization of Compounded
Oral Liquids. www.ismp.org/sc?id=2985. Published April 2014.
Accessed March 24, 2018.

https://www.ncpdp.org/NCPDP/media/pdf/wp/DosingDesignations-OralLiquid-MedicationLabels.pdf https://www.ncpdp.org/NCPDP/media/pdf/wp/DosingDesignations-OralLiquid-MedicationLabels.pdf https://www.ncpdp.org/NCPDP/media/pdf/wp/DosingDesignations-OralLiquid-MedicationLabels.pdf http://www.ismp.org/sc?id=2985

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2018