Penicillin alternatives pose risk of drug error
A drug recommendation from the federal Centers for Disease Control and Prevention in Atlanta could lead to dangerous drug errors, says the nonprofit Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.
Severe shortages of penicillin G sodium and penicillin G potassium recently led the CDC to issue a recommendation that specifically mentions penicillin G procaine and penicillin G benzathine as appropriate alternatives under certain circumstances. The ISMP, however, cautions that because those alternatives (procaine and benzathine) have been associated with repeated medication errors and because the CDC recommenda - tions are likely to increase their use, "all health care professionals [should] exercise great caution in using these alternatives."
An alert from the ISMP explains that procaine and benzathine are long-acting forms of penicillin G that must be administered intramuscularly (IM) only. Reports to the ISMP have shown that the drugs often are confused with other forms of penicillin G and administered intravenously instead.
"Name confusion, lack of general familiarity with these specific drugs among some health care professionals, ambiguous or misleading reference texts (particularly older/outdated texts), and a widely held but mistaken belief that these products may be administered IV, have typically led to the errors," the ISMP reports.
The ISMP cites this example: In 1998, three Colorado nurses were indicted in a baby’s death because long-acting penicillin was given IV instead of IM after the nurses misinterpreted information in various reference texts about the route of administration.
The ISMP offers these tips to reduce the chance of an error from the CDC recommendations:
• Place a specific reminder warning in all medication administration records stating that "penicillin G procaine and penicillin G benzathine must be administered IM only." Also, implement a similar computerized order input warning for each of those drugs.
• Apply distinctive auxiliary warning labels to those products to warn practitioners that they are intended for "IM use only."
• Examine current reference texts used in the facility to assure that information about the proper route of administration for penicillin G benzathine and penicillin G procaine is clearly communicated and prominently placed.
• Discard outdated or unclear reference texts and provide patient care areas with up-to-date and clearly written texts annually.
• Make sure ongoing staff education activities include this topic.
• Have pharmacy dispense the drug whenever possible to assure that proper auxiliary labeling is affixed and computer screening takes place before the drug is used.
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