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.

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“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.

2 Comments

  • RandallJanuary 18, 2022 at 12:43 am

    Similar for my wife. Admitted via ER on 9-11-2021 with pneumonia symptoms. Quickly swabbed and declared positive for Covid Pnuemonia. Test and xrays were withheld from us. Set for a five day stay using Remdesivir once per day, plus a hypodermic injection to the stomach daily to prevent "blood clotting". My wife is now experiencing lower back/back pain (kidney/liver), loss of taste and smell hai[Show More]Similar for my wife. Admitted via ER on 9-11-2021 with pneumonia symptoms. Quickly swabbed and declared positive for Covid Pnuemonia. Test and xrays were withheld from us. Set for a five day stay using Remdesivir once per day, plus a hypodermic injection to the stomach daily to prevent "blood clotting". My wife is now experiencing lower back/back pain (kidney/liver), loss of taste and smell hair loss, sore throat/voice loss. The hospital/attending MD's wanted to keep her for five days. We left after four. Several other issues were present. KIP above is the first we have encountered to have mentioned the stomach injections. Interested in any pending litigation.

  • KipNovember 26, 2021 at 11:18 am

    I was admitted to the hospital on sept 19th 2021 for Covid. The ER Doctor said I had pneumonia and they wanted to keep me for a few days. I was put on oxygen and transferred to a room where several IV's were installed. I am not clear of too many details of all the medications that were given to me however I do know I was given Remdesivir NaCI 0.9% rate 250.0 mis/hr total dose each time 250ml that[Show More]I was admitted to the hospital on sept 19th 2021 for Covid. The ER Doctor said I had pneumonia and they wanted to keep me for a few days. I was put on oxygen and transferred to a room where several IV's were installed. I am not clear of too many details of all the medications that were given to me however I do know I was given Remdesivir NaCI 0.9% rate 250.0 mis/hr total dose each time 250ml that I have found out so fare. Also was given some type of injection in my stomach region and I was told it was to counteract any allergic reactions. I was never consulted on my treatment and the types of drugs used and administered. I have since read a lot of information about Remdesivir and how it was basically an experimental drug and the WHO recommended it not be used in the treatment of Covid. It is my understanding that I was given this drug on two occasions during my 4 day stay in the hospital. I am worried now of long term affects , I am experiencing ringing in my ears and tingling in both feet and tremors in my hands that were not there before. I am 65 yrs old and in reasonable good health for my age. My question is has there been any malpractice and due to articles on News outlets indicating that Gilead the owner of Remdesivir has many shady arrangements with politicians. But my first worry is my health and the need to know if I have been damaged by this wreckless use of a drug without me first being consulted and given the risks. Thank you in Advance.

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