AuroMedics etomidate, pantoprazole, and bupivacaine mix-ups
A close call was reported after a nurse who retrieved a vial of pantoprazole, a proton pump inhibitor, from an automated dispensing cabinet (ADC) discovered a few vials of etomidate, an I.V. anesthetic, mixed in with the pantoprazole. Both products were produced by AuroMedics. Although bar code scanning was used to refill the ADC, the process only requires one medication vial to be scanned among the many vials that were being replaced, so the misfill was not caught. Serious patient harm could have occurred if etomidate had been administered instead of pantoprazole.
This is not the first time such a mix-up has been reported with AuroMedics products. Many of their injectable products packaged in clear glass vials have the same blue and white label colors and blue caps. The company uses various geometric shapes on the primary display panel (see Look-alike vials) to help differentiate the products. This label design strategy does not appear to be effective given a long history of error reports sent to ISMP about these products. For example, a mix-up between vials of pantoprazole and bupivacaine, a local anesthetic, from AuroMedics (http://www.ismp.org/node/31450) was reported in 2019. Administering I.V. bupivacaine instead of pantoprazole could prove fatal.
Healthcare professionals should review products purchased from AuroMedics and consider purchasing some from a different manufacturer to better distinguish between the products' appearance.
Topical gel dispensed in an ENFit syringe given via G-tube
A pain management service provider prescribed a topical gel containing amitriptyline 1%, a tricyclic antidepressant, and ketamine 1%, an N-methyl-D-aspartate receptor antagonist, for an inpatient with a gastrostomy tube (G-tube). The pharmacy-compounded gel (1 mL) was packaged in ENFit syringes, which were labeled with the ingredients and topical route of administration. The ENFit devices are not compatible with Luer connections or any other type of small-bore medical connector, thus preventing misadministration of an enteral feeding or medication by the wrong route. While administering several oral liquid medications packaged in ENFit syringes via the patient's G-tube, a nurse accidentally administered the topical gel that way, too. The topical gel was scheduled for application at the same time as the enteral liquid medications. Fortunately, there were no systemic effects from the drug, and the patient was not harmed.
Although it may not be considered a "unit dose," it would be safer to package compounded topicals in available tubes or jars. Yet, packaging topical products in oral syringes appears to be a common practice at many hospitals, compounding pharmacies, and outsourcers. After conversion to ENFit, oral syringes may no longer be available since ENFit syringes can be used in place of oral syringes. Such was the case at the hospital that reported this error.
Topical medications should never be placed in a parenteral syringe since the consequences of administering a topical medication by a parenteral route could be devastating. The primary strategy for preventing this type of error is to package a topical medication in a container that practitioners would expect, such as tubes or jars. For hospitals that must use an ENFit or oral syringe to package a topical product, affix a prominent auxiliary label that states, "For External Use Only," over the syringe cap and on the immediate container to cover any incorrect route-specific instructions. (Some syringes are labeled "For enteral use" or "For oral use," which would communicate the wrong route.)
Pharmacies should track patients with feeding tubes (which will soon all be ENFit). When possible, avoid scheduling topical medications packaged in an oral or ENFit syringe at the same time oral or enteral drugs are administered.