Instead of using 1 vial to prepare each 100 mg subsequent dose, 2 vials were used, thus providing 200 mg for each subsequent dose instead of the intended 100 mg. Remdesivir is available for use in clinical trials in at least two different dosage forms: a lyophilized powder for injection and a solution for injection. The barcode used on the product is an international pharmaceutical manufacturing code and may not be appropriately recognized by scanning systems used in the US. Tall man letters for hydroVillanova University Fitzpatrick College of Nursing has launched a national study on the experiences and self-reported health and well-being of healthcare professionals, first responders, essential workers, and service staff who are providing support for patients and the community during the COVID-19 pandemic.
If you stock the vials seen in A hospital noticed that several COVID-19-related errors were undetected before reaching patients due to a failure to engage BCMA at the bedside. The US Food and Drug Administration (FDA) list of drug names with recommended tall man letters was initiated in 2001 with the agency’s Name Differentiation Project.
Perhaps tall man letters would help COVID-19-Related Medication Errors In our April 9, 2020 newsletter , we shared an idea to add a question, “Is this event related to COVID-19 (coronavirus)?” to reporting systems to categorize COVID-19-related events, allow rapid analysis of quickly emerging risks, and reduce leadership’s reaction time in knowing about and addressing some of these issues. This resulted in further consolidation of standard medication administration times so that efforts to conserve personal protective equipment (PPE) and nurses’ time at the bedside could be continued.There is an obvious concern with Propoven 2% given its double concentration. In our One hospital analyzed numerous reports of missed medication doses for COVID-19 patients. The clinic staff are now inquiring about weight loss or gain during all telehealth encounters. The clinic is working on a process to flag weights in the electronic health record that require updating prior to prescribing, dispensing, and/or administering weight-based medications.
Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 (215) 947-7797 The hospital had implemented an investigational study using intravenous (IV) doses of remdesivir to treat patients with severe COVID-19. Table 1 provides an alphabetized list of FDA-approved established drug names with recommended tall man letters. Several studies have shown that: 1) highlighting sections of words using tall man lettering can make similar drug names easier to distinguish 2, and 2) fewer errors are made when tall man letters are used to differentiate products with look-alike names. ISMP received a report last week about a hospital compounding issue due in part to label confusion with the investigational drug remdesivir. Some facilities have received this drug, manufactured by Gilead Sciences, under a compassionate use program during a period of expanded access and through an emergency use authorization (EUA) program issued by the US Food and Drug Administration (FDA).
Updates to electronic drug databases as well as smart infusion pump drug libraries will be necessary, as typical infusion rates for propofol 1% will need to be halved with Propoven 2%.
With improved communication strategies between departments, the issue has since been resolved. You must be logged in to view and download this document.©2020 Institute for Safe Medication Practices. Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 (215) 947-7797 There are two kinds of tall-man lettering – those recommended by the FDA and those recommended by the ISMP. The patient had lost substantial weight since that time, and while double-checking the chemotherapy dose, the nurse noticed that the patient’s body surface area (BSA) was 7% lower than the BSA listed on her chemotherapy treatment plan. Use of the product may lead to overdoses if practitioners are unaware of the different concentration. 1.
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