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focus on error prevention
Ian Stewart, R.Ph., B.Sc.Phm
Toronto Community Pharmacist
Tamiflu ® oral suspension
During the outbreak of H1N1 influenza, pharmacists
are often the first point of contact for patients seeking
advice and guidance for their flu-like symptoms.
Pharmacists have also seen an increased demand for antiviral
medications such as oseltamivir for the treatment of
influenza. However, pharmacists must be aware of the potential
for error when dispensing Tamiflu® oral suspension.
Case:
Figure 1
The above prescription for an eleven-year-old child was
presented to a pharmacy technician for processing. The
technician entered the instruction for use into the computer
as “Give one teaspoonful twice daily”. The pharmacist
checked all the components of the prescription and
accurately reconstituted and dispensed the Tamiflu oral
suspension.
However, both the computer entry technician and the
dispensing pharmacist were unaware that the oral syringe
provided by the manufacturer did not include markings to
identify the volume of liquid to be administered. Instead,
the markings identified doses of 30, 45, or 60 mg only (see
Figure 1). The child’s parent would therefore be unable
to indentify ‘one teaspoonful’ on the oral syringe as the
label instructions indicated. Fortunately, during patient
counseling, the pharmacist identified the potential for error
and changed the label instructions to read “Give 60
mg twice daily”.
Possible Contributing Factors:
• The dosage of oral liquids is usually identified on the prescription
label in units of volume (milliliters) while the
manufacturer of Tamiflu® provides a syringe that identifies
the dosage in units of mass only (milligrams).
• Prior to the H1N1 outbreak, Tamiflu® oral suspension was
dispensed infrequently. As a result, both the computer
entry technician and the dispensing pharmacist were unaware
of the limitation of the markings on the oral syringe
Recommendations:
• The manufacturer of Tamiflu® oral suspension should include
on the oral syringe, the dose to be administered in
milliliters.
• When dispensing oral liquids to pediatric patients, always
provide an oral syringe that clearly identifies the volume of
liquid to be administered. Mark-A-Dose is a clear pressure
sensitive adhesive label that can be attached to the
oral syringe to identify the correct dosage.
Please continue to send reports of medication errors in confidence
to Ian Stewart at: ian.stewart2@rogers.com .
pharmacyconnection • July/August 2009
37