Minimizing Dosing Errors: Recent Examples from ISMP
- Pharmacy Practice News[T]he hospital… stocked two different versions of the experimental drug. One formulation was a lyophilized powder for injection, 100 mg, and the second was an injectable solution with an equivalent 100 mg of the drug. However, the second vial was labeled 5 mg/mL, not 100 mg—and the only clue to the vial’s actual drug quantity was a separate line on the label that read “Contents: 21.2 mL.”
The pharmacy technician who made the compounding error used the second formulation to mix the doses. Instead of adhering to the standard remdesivir infusion protocol—a loading dose of 200 mg (two vials) followed by doses of 100 mg (one vial)—the technician mixed 200-mg solutions for the subsequent and loading doses.