Packaging linked to drug mixups

"Look-alike" drugs with similar packaging are contributing to medication mixups in hospitals, a report says.

Twenty-one hospital patients fell victim to serious errors involving drugs last year, the latest report on serious and sentinel events from a ministerial advisory body shows.

Quality improvement committee member Mary Seddon said New Zealand had no national organisation monitoring "look-alike, sound-alike drugs". Medical workers were also grappling with a greater range of medications, some of them "very potent". Though medication errors were "quite common", most were "mild and fleeting".

Dr Seddon said district health boards were working on moves to cut medication errors, including standardised medication charts, automatic drug dispensing machines and electronic prescribing. "As we know, doctors have poor handwriting."

The committee's report found that more than half the 21 serious errors were overdoses or wrong doses. "In many cases, issues such as the similarity of packaging for different doses of the same medication contributed to the error."

In one incident, a patient was given 200 milligrams of a long-acting morphine called M-Eslon 10 times the dose meant to be given. The patient regained consciousness after being given an antidote.

A review found that, although the morphine came in five doses, all were in "look-alike" boxes and were kept together in one drug cupboard.

The different doses now have to be requested for individual patients, come in individual snap-lock bags with the patient's name clearly visible, and are removed once the patient is discharged.

Hawke's Bay District Health Board also reported a case in which "look-alike packaging" of narcotic medication contributed to a patient death.

Stewart Jessamine, spokesman for government drug safety agency Medsafe, said there was no committee specifically looking at the issue of naming and packaging of drugs, but it was part of Medsafe's daily work.

New Zealand made up less than 0.1 per cent of the pharmaceutical market and Medsafe could be constrained in asking manufacturers to change names or packaging. "Sometimes we have to take it with the global brand name or we don't get the medicine at all."

Improved systems for storing, checking and administering drugs were needed.

An October newsletter from the district health boards' safe and quality use of medicines group also notes incidents in which a hospital doctor had prescribed folinic acid, as part of chemotherapy treatment. A community pharmacy had dispensed folic acid. "Folinic acid is easily mistaken for folic acid on a handwritten prescription."

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