ISMP issues two special medication error alerts

Lipid-based drugs and albumin targeted

Based on patient deaths and injuries reported nationwide, the Institute for Safe Medication Practices (ISMP) in Warminster, PA, has issued "special alerts" concerning the use of lipid-based drugs and their conventional counterparts, as well as on ongoing albumin dilution errors.

ISMP notes that confusion between the use of three specific lipid-based drugs and their similar, nonlipisomal conventional counterparts has become particularly dangerous because the needed dosages of the two types "differ greatly."

Specifically, problems have been reported concerning pairings of lipid-based forms of amphotericin B (Abelcet, Amphotec, and Ambisome) and conventional amphotericin B for injection (Fungizone, and available generically); the pegylated liposomal form of doxorubicin (Doxil) and counterpart doxorubicin hydrochloride (Adria mycin, Rubex); and between a liposomal form of daunorubicin (DuanoXome, daunorubicin citrate liposomas) and conventional daunorubicin hydrochloride (Cerubidine).

To help overcome the confusion, ISMP recommends that the products not be stored together; that storage should be discouraged in patient care areas and in automated units; that preparation, labeling, and dispensing should come from the pharmacy only; and that brand name usage only be introduced along with in-house educational and warning efforts.

When pharmacies are directed to prepare albumin 5% from available 25% concentrations, too often the dilution has been done with sterile water rather than 0.9% sodium chloride or 5% dextrose, leading to reports of fatal hemolysis or renal failure in patients during large-volume infusions, according medication error reporting.

Because of this, ISMP stresses the development of written guidelines for dilution and the posting of cautions near albumin storage, as well as direct communication with staff members charged with the preparation and administration of albumin solutions.

For more information, contact ISMP at 300 W. Street Road, Warminster, PA 18974. Telephone: (215) 956-9181.