January 2005, Volume 35 Number 1 , p 14 - 15
© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(1) January 2005 pp 14-15 Fooling the robot [MEDICATION ERRORS: DRUG MIX-UP]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
The staff in a hospital pharmacy typically packaged unit doses of the calcium channel blocker nifedipine for use with robotic dispensing equipment. They used a different unit-dose packaging system for the lipid-lowering drug fenofibrate (Tricor), which wasn't used with the robotic system.
A nurse who was administering medications discovered a dose of fenofibrate in a unit-dose package labeled “nifedipine extended release 30 mg.” A review of the packaging logs and inventories for both drugs didn't reveal any errors, but the nurse said that the nifedipine package seemed to have a slight tear in it.
Further investigation ...