Pharmacy group issues warning on drug errors

Be careful with lipid-based products

A special warning from pharmaceutical professionals urges health care risk managers to head off a particular type of medication error that can occur with certain lipid-based drug products. Serious accidents already have occurred.

The warning comes from the Institute for Safe Medication Practices (ISMP) in Warminster, PA. The group recently issued a special alert to pharmacy directors and risk managers, urging them to distribute the safety message to all of their home health care organizations. Serious side effects and deaths have occurred when clinicians confused certain lipid-based drug products and their conventional counterparts.

These are the drugs and the special warnings from the ISMP:

· Amphotericin B

Medication errors, including deaths, have resulted from confusion between lipid-based forms of amphotericin B (Abelcet, Amphotec, Ambisome) and conventional amphotericin B for injection (available generically and as Fungi zone). Conventional amphotericin B for injection doses should not exceed 1.5 mg/kg/day. Doses of lipid-based products are higher but vary from product to product.

· Doxorubicin and daunorubicin

Accidental administration of the pegylated liposomal form of doxorubicin (Doxil), instead of the conventional form, doxorubicin hydrochloride, has resulted in severe side effects and death. Doxil is indicated for AIDS-related Kaposi's sarcoma. Doxorubicin hydrochloride (Adriamycin, Rubex) is used in leukemias and lymphomas, as well as breast, ovarian, and other forms of cancer. The lipid-based formulation dosing guidelines differ significantly from the nonlipid formulations because the plasma clearance of the liposomal form is reduced compared to free doxo ru bicin. The standard dose of the liposomal product is 20 mg/m2 given at 21-day intervals, compared with doses of 50 to 75 mg/m2 every 21 days for the conventional drug.

A liposomal form of daunorubicin (Dauno Xome, daunorubicin citrate liposomal) also is available and has been confused with conventional daunorubicin hydrochloride (Cerubidine). Doses of liposomal daunorubicin are typically 40 mg/m2 repeated every two weeks, while doses of conventional daunorubicin hydrochloride vary greatly and may be administered more frequently.

The ISMP advises taking these steps to prevent errors with lipid-based formulations:

· Educate all staff about the differences between conventional and lipid-based formulations of these drugs.

The education can include warnings in your internal newsletters or other publications, during new employee orientation, and during continuing education programs. The ISMP also recommends that a warning be posted in prominent locations.

· Do not store conventional and lipid-based products together in the pharmacy.

Cautionary labels or other warnings can be used to remind staff about the differences.

· Restrict the products to dispensing by a pharmacist after required preparation and labeling is accomplished.

That will ensure a redundant system of checks. Storage in patient care areas and automated dispensing equipment is not a good idea, the ISMP says.

· Encourage staff to refer to the lipid-based products by their brand names.

That will diminish the chance of confusing the products.

· Tell staff to stop and verify that the correct drug is being used if staff, patients, or family members notice a change in a solution's appearance from previous infusions.

Lipid-based products may be seen as "milky" rather than as a clear solution.

For more information on the this and other drug medication errors, contact the ISMP, 300 West Street Road, Warminster, PA 18974-3231. Telephone: (215) 956-9181. E-mail: Web site: