ISMPerroralert More confusion between opium tinctures A lthough the subject of opiate overdoses caused by accidental mix-ups of opium tincture and paregoric (camphorated opium tincture) has previously been covered in this column (November 2003, p. 16), we feel it is worth repeating because we continue to receive reports of this error. Paregoric is used to control Figure 1. Faxed prescription received by clinic diarrhea in children and adults. However, it often is dangerously referred to as camphorated opium tincture, which can be confused with opium tincture. Paregoric contains morphine in a concentration of 0.4 mg/mL, whereas opium tincture contains 10 mg/mLā??a 25-fold difference in morphine content. In a recent case, a 75-year-old woman went to her local emergency department with complaints of diarrhea. A ļ¬rst-year medical resident prescribed ā??4 oz. TR Opiumā? with the directions to take 10 mL every 3 to 6 hours as needed for diarrhea. When the patient had this prescription ļ¬lled, the pharmacist interpreted it as opium tincture rather than the intended paregoric. Unfortunately, he did not recognize that a 10-mL dose of opium tincture would deliver morphine 100 mg. The patient ingested two doses (morphine 200 mg total), became lethargic, and was taken to the emergency department. She was administered naloxone (Narcanā??Endo) to reverse the overdose and admitted to the hospital. Fortunately, she survived. Opium tincture and camphorated opium tincture are examples of high-alert medicationsā??drugs with an increased risk of considerable patient harm when used in error. Extra precautions must be taken when prescribing, dispensing, or administering high-alert medications to ensure their safe use. The following strategies can reduce the likelihood of errors: N Eliminate opium tincture from your inventory, if possible. N Use ā??paregoric,ā? the ofļ¬cial name for camphorated opium tincture in the United States, on all prescriptions, inventory lists, and labels. N Build alerts into computer systems that advise staff about appropriate dose ranges by metric weight and volume as well as maximum doses. N Place poison labels on opium tincture containers and labels with the strength of morphine (10 mg/mL) and a statement such as, ā??WARNING! Do NOT confuse opium tincture with paregoric.ā? N Educate your colleagues and students about Figure 2. Scanned prescription received by pharmacy these medications and the potential for life-threatfor veriļ¬cation. To prevent duplication of ening errors if they are confused. the prescription at a different pharmacy, record the date and time the prescription was faxed and all relevant information on Scanners can chop text the original. A prescription for a patient with a prosthetic heart valve who was to ā??Institute for Safe Medication undergo a cystoscopy was faxed from Practices the physicianā??s office to the clinic (Figure 1). The faxed copy was then scanned and sent to the hospital pharmacy (Figure 2). The pharmacist read the gentamicin dose as ā??5 mg/kgā? and thought the calculated dose was within range for a single daily dose. She did not realize that the notation ā??pt has heart valveā? on the order indicated that the gentamicin was for subacute bacterial endocarditis prophylaxis, which requires a lower dose of 1.5 mg/kg. The order for the higher dose was dispensed and the infusion started. Minutes later, a nurse noticed the error and called the pharmacy for the lower dose. The pharmacist then realized that the prescription was for 1.5 mg/kg, but the number ā??1ā? and decimal point had been cut off during scanning. To manage this risk, implement safeguards for the fax process. Design prescriptions and order forms with margin lines to indicate areas beyond which writing is not permissible and that allow adequate space for holes to be punched in the forms. Check the faxed order against the original, if available. Prescribers should give the original prescription to the patient to present at the pharmacy The reports described in this column were received through the USPā??ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the Institute for Safe Medication Practices (www.ismp.org) or U.S. Pharmacopeia (www.usp.org) Web sites or communicated directly to ISMP by calling 800-FAIL-SAF (800-324-5723) or e-mailing ismpinfo@ismp.org. The topics in this column are covered in greater detail in Medication Errors, 2nd edition, written by ISMP President Michael R. Cohen, BPharm, MS, ScD. The book may be purchased from APhA at www.pharmacist.com or by calling 800-878-0729. 72 PHARMACY TODAY s FEBRUARY 2008 www.pharmacytoday.org