ISMP warning: Providers confuse Carpuject syringes
Follow 5 tips to avoid drug mix-up
In an ambulatory surgery center that was busy recently handling several patients, two patients received two doses of fentanyl instead of one dose each of fentanyl and midazolam, according to the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.1
The errors were found when counting narcotics, according to the ISMP. No patient harm occurred, but this is one of many reports that ISMP has received regarding errors with look-alike Carpuject syringes from Hospira in Lake Forest, IL.
All of the Carpuject syringes now have green caps, says Michael Cohen, RPh, ScD, ISMP president. "At one time, they were color-differentiated," Cohen says. The company has retained color differentiation for the drug name on the syringe. Additionally, the midazolam information is boxed to differentiate the products.
Hospira uses its enhanced product labeling to distinguish each medication, not the green caps which only indicate that the product has a luer tip, says Shannon Gore, a spokeswoman for Hospira. Hospira encourages clinicians to take advantage of differentiating features on the product labeling when selecting drugs, she says. For example, Gore adds, key differences in the fentanyl and midazolam product labels include:
- color: Fentanyl has a red label and midazolam has an orange label;
- capitalization: The name "midazolam" contains all capitalization and has a box around the name and dosage;
- units of measure: Fentanyl is dosed in micrograms, and midazolam is dosed in milligrams;
- classification: Fentanyl is labeled as a Class C-II controlled substance, and midazolam is labeled as a C-IV controlled substance;
- bar code: Fentanyl and Midazolam have unique bar codes to differentiate the products.
ISMP offers five tips to reduce the risk of errors with Carpuject syringes:
- Identify Carpuject products that are prone to mix-ups, and separate the storage of these products.
- Place Carpuject products in automated dispensing cabinets in discrete pockets, never together.
- Ask pharmacy staff to apply auxiliary labels to the outer cartons.
Outpatient surgery providers who don't have pharmacy staff could circle the name of the drug to call attention to it, Cohen says.
- If the syringes are stored in the carton, leave the carton flap that lists the drug name and strength intact.
- Consider requiring an independent double check of selected Carpuject narcotics prone to mix-ups.
This step is especially needed if the drugs are being given intravenously, Cohen says. "With opiates, all of these, there can be such a potency difference in the drugs," he says. When given intravenously, the patients would be immediately affected if there is an overdose, Cohen says. "It's always better where possible to have a second individual look at the label to make sure you have the correct drug and dose," he says.
(Editor's note: Five tips are reprinted with permission from June 2006 issue of ISMP Medication Safety Alert Nurse Advise-Err newsletter. For more information, see www.ismp.org.)
In an ambulatory surgery center that was busy recently handling several patients, two patients received two doses of fentanyl instead of one dose each of fentanyl and midazolam, according to the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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