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- Dispensing Errors
- Food and Drug Administration (FDA)
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.
This announcement reveals a labeling change to reduce the potential for misadministration of a pain medication.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 25, 2009.
This announcement explains the potential for medication errors due to a discrepancy between dosing instructions and dosing dispenser measurement units for the drug Tamiflu.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 13, 2007.
This announcement provides specific instructions on safe prescribing of a cancer pain medication in response to several patient deaths associated with off-label use.
Roxane Laboratories Initiates a Nationwide Voluntary Recall of a Single Manufacturing Lot of Azathioprine Tablets in the U.S. and Puerto Rico.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 13, 2006.
This news release announces the recall of a manufacturing lot of Azathioprine. Bottles may have been erroneously filled with another medication, which could lead to serious health effects for those taking the drug.
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.