Inappropriate ADC overrides
One of the biggest challenges to the safe use of automated dispensing cabinets (ADCs) is the ease with which medications can be removed upon override, often unnecessarily and with a lack of perceived risk. ISMP's affiliate, ECRI, recently released the Top 10 Health Technology Hazards for 2023 (http://www.ismp.org/ext/1079). Coming in at number 3 is the inappropriate use of ADC overrides and how they can result in medication errors. We encourage organizations to review the ISMP Targeted Medication Safety Best Practices for Hospitals, Best Practice #16: http://www.ismp.org/ext/986, and implement the following recommendations:
* Limit the variety of medications that can be removed from an ADC using the override function.
* Require a medication order (such as, electronic, written, telephone, verbal) before removing any medication from an ADC, including those removed using the override function.
* Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.
* Periodically review the list of medications available using the override function for appropriateness.
Pediatric strength Biktarvy accidentally prescribed and dispensed to adults.
ISMP has received multiple reports in which an adult patient was ordered and dispensed the pediatric strength of Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) in error. Biktarvy is indicated as a complete regimen for the treatment of HIV-1 infection in adults and pediatric patients weighing at least 14 kg who have no antiretroviral treatment history or to replace the current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure and no known substitutions associated with resistance to the individual components of Biktarvy.
In one case, an adult recently diagnosed with HIV infection was discharged from a hospital with a new prescription for Biktarvy 30 mg/120 mg/15 mg tablet once daily. This dose is appropriate for pediatric patients weighing at least 14 kg to less than 25 kg, but not for adults. The recommended dosage in adults and pediatric patients weighing at least 25 kg is 50 mg/200 mg/25 mg once daily.
In the error described above, the community pharmacist did not recognize that this was an underdose and dispensed the medication to the patient. The patient's partner, prescribed Biktarvy from an HIV clinic, told the patient that the label on the bottle looked different, so they contacted the HIV clinic. It was then discovered that the prescriber ordered the pediatric formulation in error. The label does not indicate the intended weight range or specify that it is a pediatric formulation (see Biktarvy tablets). In addition, it is unclear if the hospital or retail pharmacy had a dose range checking alert set up in the electronic health record (EHR) to confirm the prescribed dose.
The practitioners involved in prescribing and dispensing this medication were not familiar with HIV medications and their various formulations, which could have contributed to the error. In a second report, a prescriber ordered the pediatric dose of Biktarvy for an adult patient, and a retail pharmacist dispensed it to the patient for 8 months before discovering the underdose. The health system completed an audit and identified another adult patient who was also prescribed the pediatric dose in error upon discharge.
Another pharmacy reported that they accidentally purchased the pediatric formulation because they were not aware there were two strengths available. The bottle was dispensed to an adult patient before the pharmacy recognized the error.
We reached out to the manufacturer, Gilead, and recommended they include a prominent pediatric or weight-based specification on the Biktarvy 30 mg/120 mg/15 mg label; they will escalate this concern. For now, educate any healthcare provider involved with prescribing and/or dispensing this medication about the two formulations along with the corresponding weight ranges.
Create weight-based orders with dose range checking in the EHR to guide prescribers to select the correct dose and automatically link the corresponding formulation in the pharmacy system.