Put Your Money on Safety

Problem

We here at the Institute for Safe MedicationPractices often hear aboutstrategies that are employed to reducemedication expenditures for patients ororganizations. Although many of thesestrategies are quite effective at savingmoney while enhancing or preservingpatient safety, some may actually workto compromise patient safety along theway. For example, one rheumatologist'scommon practice of prescribing injectablemethotrexate for oral administrationnearly led to serious harm. Thisunusual use of an injectable productwas initiated to save his patientsmoney, because the injectable productis much cheaper than the tablets on aper-milligram basis.

When one of the rheumatologist'spatients was hospitalized, however,the patient's wife told a nurse practitionerthat her husband took 80 cc ofmethotrexate injection weekly. Thenurse practitioner subsequently ordered"methotrexate injection 80 ccevery Sunday." Actually, the patienthad been prescribed 0.8 mL (20 mg) ofinjectable methotrexate weekly, as anoral dose. The patient's communitypharmacist had dispensed the drugwith insulin syringes and told thepatient to draw up 80 units, mix themedication with orange juice, andthen drink it. The patient's wife confusedunits with cc when stating thevolume of medication that her husbandtook. It is not clear whether thepatient was given insulin syringesbecause he was already familiar withthem, or whether the pharmacy didnot carry tuberculin syringes. An oralsyringe would have been more appropriatefor the dosing regimen, but itdoes not permit the withdrawal ofsolution from an injectable vial. Confusionbetween units and cc mighthave been avoided if the patient hadbeen using a tuberculin syringe todraw up his medication (although, inthis case, we do not recommend usingthe injectable product orally).

Because the concentration of theinjectable methotrexate was 25mg/mL, the nurse practitioner's ordercould have led to a 2 g overdose. Tomake matters worse, the nurse caringfor the patient did not realize that theinjectable product was supposed to begiven orally! Fortunately, a hospitalpharmacist noticed the error andaverted a potentially fatal case ofmyelosuppression.

In another cost-versus-care example,officials at an ambulatory clinic made adecision to offer free emergency contraception(EC). Because this was a freeservice, the clinic personnel looked forthe most cost-effective treatment regimen.They decided to use Ovral(norgestrel/ethinyl estradiol) instead ofPlan B (levonorgestrel) due to a significantcost savings. (The per-patient treatmentcost of Ovral is about half that ofPlan B.) Ovral is packaged in 21- and 28-day blister packs intended for ongoinguse in preventing pregnancy. Whenused for EC, patients take 2 Ovral tabletswithin 72 hours of unprotected intercourseor known or suspected contraceptivefailure. This dosage is followedby an additional 2 tablets 12 hours afterthe first dose. Plan B is specially packagedand labeled for individual use inEC. Patients take 1 tablet within 72hours of unprotected intercourse orknown or suspected contraceptive failure,followed by 1 tablet 12 hours later.

The clinic protocol for EC was for thenurse practitioner to dispense 4 Ovraltablets and to instruct the patient to take2 tablets immediately and 2 tablets in 12hours. In this instance, the nurse practitioner,possibly familiar with the 2-tabletdosing regimen of Plan B, dispensedonly 2 Ovral tablets. The error was discovered5 weeks later, when the patienthad a positive pregnancy test. Whenquestioned about the medication, thepatient reported that she had received 2tablets at her previous visit. The patientwas informed of the error and decided tocontinue with the pregnancy. The clinicpersonnel reported that they would lookinto getting a prepackaged, ready-to-useform of EC in order to prevent similarerrors from occurring.

Safe Practice Recommendations

Although affordability is an ever-presentissue that affects access to medications,health care practitioners mustcarefully weigh affordability againstpatient safety issues when cost-savingmeasures are employed. When medicationsare dosed or used in an unconventionalmanner in an effort to containcosts (yet another example wouldbe tablet splitting), health care practitionersshould consider the following:

• Before implementing any newcost-saving strategy, proactivelyconsider the types of errors thatcould occur as a result of this strategy.For example, consider therisks/difficulty involved with anarthritic patient manipulating asyringe to draw up an injectableproduct in order to take it orally.
• Identify the potential risks associatedwith using the medication inthis manner, and determinewhether the risk justifies the costsavings. The person who reportedthe methotrexate error abovenoted that her hospital has recognizedthe practice of using aninjectable product for oral use aserror-prone. So, to minimize therisk of error, the hospital's policyno longer permits the oral use ofinjectable methotrexate.
• Verify the patient's medicationhistory, using sources other thanthe patient or family members, if these sources arenot reliable; if the information provided seemsunusual; or if the appropriateness of the dosing regimenis questionable.
• If it is decided that the cost savings justify the use ofthe medication in an unconventional manner,employ methods to minimize any risks. For example,in the case above, the clinic could prepackage 4 Ovraltablets in ready-to-use kits that include an explanationas to how to take the medication properly.
• Whenever possible, involve a pharmacist in the dispensingprocess. The EC error might have been avertedif a pharmacist had been involved. Clarify anyorder that is incomplete. It is dangerous to write oraccept orders without a route of administration orwith only a volumetric dose (eg, "methotrexate injection80 cc every Sunday"), even if the product isavailable in a single concentration or by a singleroute.
• Educate patients, caregivers, and involved practitionersthat the medication is being used in an unconventionalmanner. Counsel patients regarding how to use themedication, as well as about the potential risks involvedwith using the medication in such a way.

Drs. Kelly and Vaida are both with theInstitute for Safe Medication Practices(ISMP). Dr. Kelly is the editor of ISMPMedication Safety Alert! Community/Ambulatory Care Edition, and Dr. Vaidais the executive director of ISMP.

Report Medication Errors

The reports described here were received through the USPMedication Errors Reporting Program, which is presented incooperation with the Institute for Safe Medication Practices(ISMP). ISMP is a nonprofit organization whose mission is tounderstand the causes of medication errors and to provide time-criticalerror-reduction strategies to the health care community,policy makers, and the public. Throughout this series, the underlyingsystem causes of medication errors will be presented tohelp readers identify system changes that can strengthen thesafety of their operation.

If you have encountered medication errors and would like toreport them, you may call ISMP at 800-324-5723(800-FAILSAFE)or USP at 800-233-7767 (800-23-ERROR). ISMP's Webaddress is www.ismp.org.

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Pharmacy Times and the Institute for Safe MedicationPractices (ISMP) would like to make community pharmacypractitioners aware of a publication that is available.The ISMP Medication Safety Alert! Community/AmbulatoryCare Edition is a monthly compilation of medication-relatedincidents, error-prevention recommendations, news,and editorial content designed to inform and alert communitypharmacy practitioners to potentially hazardous situationsthat may affect patient safety. Individual subscriptionprices are $45 per year for 12 monthly issues. Discountsare available for organizations with multiple pharmacysites. This newsletter is delivered electronically. For moreinformation, contact ISMP at 215-947-7797, or send an emailmessage to community@ismp.org.