Risk of medication errors with zuclopenthixol

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We alert readers to the ongoing risk of errors when prescribing and dispensing zuclopenthixol for injection.

The two formulations available are zuclopenthixol acetate (Clopixol Acuphase®; Lundbeck Ltd) and zuclopenthixol decanoate (Clopixol® and Clopixol Conc®; Lundbeck Ltd), but they have very different release profiles.

Zuclopenthixol acetate is indicated for short-term management (maximum duration of treatment should be two weeks) of acute psychosis, mania or an exacerbation of long-term psychosis, and has a duration of action for two to three days after injection. Whereas, zuclopenthixol decanoate is indicated for maintenance treatment in schizophrenia and paranoid psychoses, and is administered regularly at intervals of between one and four weeks.

However, we have recently become aware of an individual who was prescribed zuclopenthixol acetate, within primary care, on a regular basis over a period of six months. The medication was dispensed by a community pharmacist and administered by nursing staff within a care home setting. Fortunately, this individual has come to no harm, but we are also aware of other prescribing or selection errors occurring with this drug in the past few years in our area.

We would ask all pharmacies to consider the storage of zuclopenthixol injections to ensure that inadvertent selection of the incorrect formulation cannot occur. In addition, we would encourage all pharmacists to question any prescription for zuclopenthixol acetate to ensure that the correct formulation has been prescribed. Although there are automated alerts on some prescribing and dispensing systems, it is possible to override these or to become fatigued by numerous alerts.

The similarity in appearance of the two products is also of concern, and we would encourage the manufacturer to review the design of the two boxes and font size of the warning that the acetate formulation is for initial treatment only.

Alison Marshal, acting deputy chief pharmacist, Surrey and Borders Partnership NHS Foundation Trust; Nikki Smith, patient safety lead for medicines, Surrey Heartlands Integrated Care System; Lis Stanford, acting head of medicines optimisation, NHS Surrey Heartlands Clinical Commissioning Group


A spokesperson from Lundbeck Ltd said:

Lundbeck takes patient safety seriously. We continuously monitor all reports of safety incidents, which includes risk of medication errors, and we investigate accordingly. We take appropriate action in the event any new risks are identified. We encourage the reporting of adverse and potential adverse events directly to Lundbeck by using the online contact form.

Last updated
Citation
The Pharmaceutical Journal, PJ, July 2021, Vol 307, No 7951;307(7951)::DOI:10.1211/PJ.2021.1.92258