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Awareness needed to prevent dosing errors with IV acetaminophen
Dart RC. Pediatrics. 2012;doi:10.1542/peds.2011-2345.
A newly available intravenous formulation of acetaminophen has been associated with dosing errors in pediatric patients, according to study results published online.
Richard C. Dart, MD, PhD, and colleagues at the Rocky Mountain Poison and Drug Center at Denver Health in Colorado recently published recommendations, which aim to reduce iatrogenic dosing errors of IV acetaminophen.
Researchers found that in Europe, where the medication has been available, “most overdose errors involved a 10-fold dosage error in young children caused by calculating the dosage in milligrams, but then administering the solution in milliliters.”
Dart and colleagues anticipate similar problems in the United States with the medication, which is distributed as 10 mg/mL.
The researchers said although most IV overdoses had a faster peak concentration, overdose treatment is similar to oral overdose — serum acetaminophen concentration evaluation and administration of acetylcysteine according to the treatment line of the Rumack-Matthew nomogram. They also encourage the reporting of dosing errors and “proactive consultation with your hospital’s department of pharmacy and nursing staff when this product is added to the formulary.”
Disclosure: A number of the researchers reported consulting with Cadence Pharmaceuticals, which developed IV acetaminophen.
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The paper by Dart and Rumack sheds light on the potential for significant dosing errors and resultant toxicity with a newly approved (in the US) IV acetaminophen product, Ofirmev (Cadence Pharmaceuticals), for use in children aged 2 years and older. Data from the United Kingdom indicate that 10-fold dosing errors have occurred as a result of calculating a patient-specific dose in milligrams but administering the IV dosage form (which is 10 mg/mL) as milliliters. Discussion in this paper centers mostly upon the pathophysiology and pharmacotherapy of acetaminophen overdosing and toxicity. As the best method to reduce medication errors is prevention, it is important to review this as well. Health care professionals, institutions and caregivers can use various methods to reduce the risk of medication errors. Computerized order entry systems can help to minimize the risk of medication errors through a variety of safeguards when medication orders are entered and verified.
As this new IV acetaminophen is available as only one concentration — 10 mg/mL — a computerized entry program can be customized to highlight the potential for error by dose expression as “mg” and “mL.” Patient-specific dose order entry can be expressed as milligram/kilogram, as well as a milligram dose, and the patient’s weight should be included for dose verification. Dose verification, or double-check, by nurses and pharmacists is also important to implement. Various other methods to prevent medication errors have been previously well described and are widely available (pediatric pharmacy guidelines available at www.ppag.org, as well as guidelines and recommendations from the AAP).
Edward A. Bell, PharmD, BCPS
Infectious Diseases in Children Editorial Board
Disclosure: Dr. Bell reports no relevant financial disclosures.
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