ISMP Warns Of Medication Errors Linked To COVID-19 Response

The ongoing COVID-19 pandemic has not only increased the risk of potentially deadly infections worldwide, but a new report suggests it may also be increasing the risk of medication errors, as healthcare workers rush to contain the virus and limit the loss of life.

The Institute for Safe Medication Practices (ISMP) issued a special edition of its Medication Safety Alert! Acute Care newsletter on May 14, warning about emerging medication problems linked to the COVID-19 pandemic.

The alert warns of errors and confusion with the Gilead Sciences drug remdesivir, which is being investigated as a potential treatment for the virus. ISMP indicates that it learned of a hospital compounding error involving remdesivir, which it says was partly due to label confusion.

“The hospital had implemented an investigational study using intravenous (IV) doses of remdesivir to treat patients with severe COVID-19. The adult protocol called for an initial loading dose of 200 mg, followed by subsequent 100 mg doses,” the report notes. “Each vial of remdesivir contains a total of 100 mg. Instead of using 1 vial to prepare each 100 mg subsequent dose, 2 vials were used, thus providing 200 mg for each subsequent dose instead of the intended 100 mg.”

The ISMP worries this mistake could occur at other hospitals, due to vials not being clearly labeled, and information being presented in crowded and small font.

Remdesivir is an investigational drug which is available for use in clinical trials and through an emergency use authorization program approved by the FDA. However, the label problem is one that is common with such investigation drugs, according to the ISMP.

The ISMP report recommends each remdesivir container carry a printed barcode label which can be used for product and dose verification. It also recommends pharmacies put an auxiliary label on individual vials indicating the total amount of the drug contained within each one.

The report also list a number of other medication errors being seen as the pandemic progresses, including failures to use barcode medication administration protocols, as well as problems with health care professionals’ inability to weigh patients when seeing them through videoconferencing, referred to as telehealth encounters.

Many particularly potent drugs are prescribed based on patient weights.

The report also warns of problems with missed medication doses due to communication breakdowns during the initial stages of the pandemic, as well as an increase in drug name errors and confusions.