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  1. Cohen, Michael R. ScD, MS, RPH

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Don't be thrifty with single-dose vials

In a facility without 24-hour pharmacy service, a nurse received a prescription for promethazine injection, a potent H1 receptor antagonist with additional antiemetic and sedative/calming properties, after pharmacy hours. Because nurses had been made aware of a shortage of this drug, the nurse labeled the vial with that patient's room number, the date of opening, and the amount used (see photo), then saved the vial for future doses. In the morning, she told the pharmacist that she'd done so because she knew the medication was in short supply.


In a desire to conserve supply, and without recognizing potential problems, some practitioners have been saving any content remaining in single-dose vials after withdrawing the dose needed for a patient, but this practice is unsafe. Single-dose vials are intended to provide only one dose to one patient. Any drug remaining in a single-dose vial after drug administration should be disposed of according to facility policy. Educating clinicians about proper use of single-dose vials can help prevent this type of error.

Figure. This partial... - Click to enlarge in new windowFigure. This partially used vial of promethazine injection was improperly saved for future use.

In this case, nothing on the promethazine vial label indicated it was a single-dose vial, which is not a requirement for manufacturers when small vial labels have insufficient space. Whenever possible, it's safest to have pharmacy prepare and dispense patient-specific doses.



These capsules shouldn't be swallowed

AcipHex Sprinkle (RABEprazole sodium) is a proton pump inhibitor (PPI) used to treat gastroesophageal reflux disease in children ages 1 to 11 years for up to 12 weeks. The drug is provided as granules in a delayed-release capsule that must not be swallowed whole or chewed, nor should the granules be crushed. Instead, patients or caregivers should open the capsule and sprinkle the granules on a spoonful of soft food or liquid, and take the entire mixture within 15 minutes of preparation. This is the only capsule formulation PPI that can't be swallowed whole. All other PPIs in capsule form, such as omeprazole, esomeprazole, and lansoprazole, can be swallowed whole, or the capsule can be opened and the contents sprinkled on applesauce for patients who have trouble swallowing.


Unfortunately, some of the auxiliary labels that automatically print along with pharmacy labels for AcipHex Sprinkle capsules may be misinterpreted to mean that the capsules can be swallowed whole, as shown at right. If applied to the prescription bottle, such a label can confuse caregivers about the administration method and increase the risk of incorrect administration in older children who may try to swallow the capsules. When the Institute for Safe Medication Practices (ISMP) contacted the manufacturer's medical information group, the company couldn't comment on the clinical and safety outcomes for patients who swallow these capsules whole.


Nurses need to be made aware of the correct administration method, either through built-in administration instructions in the electronic medical record or via other drug information resources, so they can educate patients and caregivers accordingly. In addition, retail pharmacies should evaluate the medical information pamphlet and auxiliary labels programmed to print with AcipHex Sprinkle prescriptions to be sure they reflect the correct administration method. ISMP has contacted all major drug information vendors so they can make any necessary changes to auxiliary warnings they provide in their content for pharmacies.

Figure. Auxiliary la... - Click to enlarge in new windowFigure. Auxiliary labels printed with AcipHex Sprinkles prescription labels are misleading. They imply that AcipHex Sprinkles should be swallowed whole, which is incorrect. These capsules should always be opened and the contents sprinkled on food or liquid.