Many patients being given the wrong medicine has led to a recommendation that Buscopan (hyoscine butylbromide) and baclofen be stored separately.
The UK medicines information (UKMi) network reveals that the number of reports of the wrong product being dispensed shows the error is happening too often. Although there was a very low risk of patient harm by confusing the two medications, the UKMi said steps were needed to ensure the medicines were identifiable.
The UKMi conducted a product safety assessment which highlighted three key areas of their presentation that may increase the likelihood of confusing the two medications. It found the look and sound of their names are similar and their packaging design is close, as is the proximity of the medicines in the dispensary, which usually store products in alphabetical order.
The UKMi recommends that generic baclofen from Actavis is the least likely to cause confusion, because, compared with three other generic baclofen products produced by Teva, Almus and Mylan, the packaging colour is the most distinct from the Buscopan packaging. Buscopan bears a bright yellow and green colour combination and the UKMi has suggested that generics manufacturers of baclofen should update their choice of packaging colour to make it as different from Buscopan as possible and that the manufacturer of Buscopan increase the size and prominence of the generic name of the medicine. Furthermore, it is recommended that the two medicines are stored according to their generic names, hyoscine butylbromide and baclofen, so that they are further apart in the dispensary.
In a separate safety report, the UKMi has looked at the potential for confusing subcutaneous trastuzumab (Herceptin) with intravenous trastuzumab (Herceptin) or the distinct medicine, trastuzumab emtansine (Kadcyla), which are all marketed by Roche and so have similar packaging. Although the safety assessment does not mention any incidents being reported in practice, prior to September 2013 only the intravenous preparation of trastuzumab was available and the UKMi says that “availability of three trastuzumab products on the market increases the potential for error through misselection at the point of prescribing, preparation/supply and administration”.
The UKMi says that “whilst it is clear that trastuzumab emtansine and trastuzumab are different medicines, this is a very difficult message to communicate to healthcare staff where a culture of referring to medicines by their generic name is generally encouraged and in which the salt ‘suffix’ is often ignored as being clinically irrelevant”.
Owing to the “high potential for error”, the UKMi recommends that these products be prescribed using both the generic and brand name and that prescribing systems need to be reviewed in order to minimise the likelihood of prescribing the wrong product. In addition, pharmacy staff should remain “alert” to the possibility of selecting the wrong product. The UKMi also suggests that the introduction of trastuzumab emtansine (Kadcyla)-specific stickers should be considered.
- The image for this story was changed on 01 October at 4.22pm to more accurately portray a dispensery.