An oncology clinic reported an unintended consequence of telehealth visits-the inability to document an accurate weight, leading to incorrect dosages of weight-based drugs. In this case, the patient had come into the clinic for her first chemotherapy treatment-protein-bound PACLitaxel and gemcitabine. Due to the COVID-19 pandemic, the patient had been participating in telehealth visits for several months prior to her first chemotherapy treatment, during which measured weights were not obtained or regularly updated. The patient's weight had not been measured or updated for 4 months; however, a weight was obtained when she arrived at the oncology clinic for her first dose of chemotherapy. Unfortunately, the chemotherapy plan was based on the previous weight measured 4 months prior. 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. In this organization, a BSA difference of 5% or greater requires a change in the dose; however, it took more than 2 hours to authorize a revised dose based on the patient's current BSA, delaying the beginning of chemotherapy administration. 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. The clinic staff also is now inquiring about weight loss or gain during all telehealth encounters.

Confusion Over Antiretroviral Therapy Abbreviation

A patient received the wrong antiretroviral drug due to confusion with a drug name abbreviation. Like vaccine abbreviations, antiretroviral drugs have been assigned drug name abbreviations that can increase the risk of confusion (http://www.ismp.org/ext/306). In this case, the physician intended to prescribe PIFELTRO (doravirine), which is commonly abbreviated as DOR in most literature on therapies used to treat HIV infections. During order entry, the prescriber was thinking DOR but accidentally selected DOVATO (dolutegravir and lamiVUDine), which starts with DOV, as the prescribed antiviral medication. Both drugs are taken once daily and are available in a single strength (Pifeltro 100 mg, Dovato 50 mg/300 mg). Thus, when prescribing either drug, the strength does not need to be selected. Therefore, the prescriber did not notice the difference between the intended 100 mg dose of Pifeltro and the 50 mg/300 mg dose of Dovato. Because both drugs are used to treat HIV infection, the pharmacist was not able to identify the prescribing error without knowing the patient's resistance profile and specific intended therapy. As the intended drug, Pifeltro, may be paired with lamivudine. In this case, it was also unknown if the patient was already taking lamiVUDine, which might have led to a duplicate therapy warning because the erroneously prescribed drug, Dovato, contains lamiVUDine. Mix-ups are also possible between other antiretrovirals with commonly used drug name abbreviations (e.g., TAF [tenofovir alafenamide] and TDF [tenofovir disoproxil fumarate]). This is a prime example of why drug name abbreviations should be prohibited. Medication administration records should not include abbreviations for antiretroviral medications or any other medications. When doing drug name searches, using technology, require entry of at least the first 5 letters of the actual drug name, and not an abbreviated drug name.

Should the PillCrusher Syringe be Used for Crushing Tablets?

In light of USP <800>, hospital pharmacy staff reported evaluating potential devices for pill crushing. One that stood out was the 60 mL PillCrusher syringe, which is an enteral syringe that can be used to crush and dissolve tablets while contained in the syringe. According to the manufacturer, this can also be used to administer medication directly to the patient (http://www.ismp.org/ext/836). The syringe can also be used for enteral irrigation. A YouTube video demonstrates how the syringe is used (http://www.ismp.org/ext/344).

The Welcon brand PillCrusher syringe by Nurse Assist is available through several medical equipment distributors. The pharmacy staff decided to try it out with a tablet that nurses found hard to crush-sodium chloride 1 g tablets (Westminster Pharmaceuticals). When they tried to crush the tablet per the manufacturer's instructions, the tablet "shredded" the plunger's plastic grinding teeth and some other plastic components, while the tablet was barely scathed. Incidentally, the syringe has a tapered tip used to connect with feeding tubes but is not ENFit compatible. It also has an orange cap that could be a choking hazard if the capped device is used for oral administration or if the cap is left at the bedside or around children.

The company warns against use for tablets that are not supposed to be crushed (e.g., long-acting, enteric coated). Still, nurses who use these syringes may not know which tablets should not be crushed with this device. As healthcare organizations transition to ENFit, having a syringe that is not compliant, that cannot crush all medications, and where you might get plastic residue from the teeth seems to severely limit its usability. We, therefore, suggest using another type of pill crusher, and transferring the crushed tablet to a cup and/or ENFit oral syringe for dilution and administration.

Good communication between nurses and pharmacists is a must when dosage forms need to be altered (crushed) or changed (tablet to liquid). Some pharmacies assist nurses by crushing the tablets while in their unit dose packaging, using another means of preparing and packaging a crushed tablet dose, or replacing tablets with unit dose liquids when possible. Also, many tablets can be dispersed in water without the need for crushing, and drawn into an oral/enteral syringe, as with dry powder immediate-release capsule contents. In this case, the standard tip ENFit devices would work. ASPEN has a safe enteral nutrition practices document with a section on medications via feeding tube (Boullata et al., 2017), as well as a Guidebook on Enteral Medication Administration (http://www.ismp.org/ext/352).

E-cigarette use may lead some to quit traditional cigarettes

NIH: Studies have been investigating whether e-cigarettes can help people who smoke to quit traditional cigarettes. Most of these studies have focused on smokers who were already planning to quit. But those with no plans to quit smoking tend to smoke more cigarettes per day and often have the highest risk for poor health outcomes from smoking. A team of researchers has been examining data collected between 2014 and 2019 in the Population Assessment of Tobacco and Health (PATH) study, a long-term study of tobacco-use patterns and health outcomes in the United States. In the study, the researchers examined whether e-cigarette use was associated with quitting cigarette smoking among daily smokers who weren't planning to quit. The researchers looked at 1,600 adults who smoked cigarettes daily, did not use e-cigarettes, and were not planning to quit smoking at the beginning of the study. About 6% quit cigarettes altogether during the study. Another 4.5% reduced their smoking to less than one cigarette a day. The team compared quit rates between those who took up e-cigarettes and those who did not. Those who were using e-cigarettes daily at the end of the study were 8-fold more likely to quit cigarettes altogether. They were also almost 10-fold more likely to stop smoking cigarettes every day.

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