ISMP warns of errors with Celebrex, ferrous sulfate
The Institute for Safe Medication Practices (ISMP) in Fultom, MD, is cautioning health care providers about potentially dangerous errors involving the drug Celebrex and a liquid ferrous sulfate solution, urging risk managers to pass the warning on to their clinicians.
The first problem concerns Celebrex (generic celecoxib), a new drug released recently by Searle and co-marketed by Pfizer. The ISMP reports that there have been at least 40 documented medication errors involving Celebrex in the first two weeks of its release, in addition to a number of near misses. The problems stem from the fact that the Celebrex name looks and sounds similar to two other existing drugs, the ISMP says.
In a special warning issued recently to health care providers, the ISMP explains that Celebrex can be confused with Celexa (citalopram hydrobromide), an antidepressant from Forest Pharmaceuticals, and Cerebyx (fosphenytoin), a drug for seizure disorders from Parke-Davis.
"Most errors have so far resulted from misinterpretation of written orders," the ISMP reports. "However, the potential for sound-alike errors in verbal orders is also high, particularly for prescribers and others for whom English is a second language. This is especially true for those spoken accents in which it might be difficult to differentiate between the L and R sounds in the middle of words."
Ways to prevent drug errors
These are some the precautions that the ISMP recommends risk managers implement:
• Prescribers should always include the purpose of the medication on the prescription order for all three of these drugs.
• Prescribers should be reminded to print prescriptions clearly.
• Prescribers should use both the generic and brand names.
• An alert should be added the pharmacy or hospital computer system warning the user to question the prescription if an indication for the drug is not clearly stated on the order.
• Pharmacists, nurses, and other practitioners should repeat verbal orders back to the prescriber and clearly communicate the drug’s indication.
Ferrous sulfate warning
In a separate warning, the ISMP is pointing out the dangers of what it calls an ambiguous label on a ferrous sulfate solution. The liquid ferrous sulfate product manufactured and distributed by Hi-Tech Pharmacal Company is labeled on the front panel as both "ferrous sulfate solution" and "iron supplement drops." The actual strength of the product is ferrous sulfate 75 mg (15 mg elemental iron) per 0.6 mL, similar to other ferrous sulfate products labeled as drops.
The ISMP cautions that the label’s use of the term "ferrous sulfate solution" is ambiguous because there is no such product. Ferrous sulfate drops have about three times as much iron per mL as ferrous sulfate elixir and about seven times as much as ferrous sulfate syrup.
At least one incident has been documented in which a child was given the Hi-Tech product when ferrous sulfate elixir was prescribed, the ISMP reports. The mistake was discovered before the child was harmed.
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