Multidose Nitroglycerin Bottles Associated With 25-Fold Overdose Errors
Strategies for safe dispensing and administration of nitroglycerin tablets to prevent an unintended overdose
The Patient Safety Authority has received multiple reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing erroneous dispensing and administration of whole bottle contents (up to 25 tablets) of sublingual nitroglycerin instead of a single tablet. As a result of these events, patients have required resuscitative measures and/or transfer to a higher level of care.
Sublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease.1 The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air.2 The loss of potency from environmental exposure2 often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses prepackaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur.
PRN [i.e., prescribed “as needed”] sublingual nitroglycerin was ordered for a patient experiencing chest pain. After scanning the patient’s wristband and the bottle, the nurse administered the full bottle to the patient. The patient vomited and became hypotensive. A rapid response was called, fluids were administered, and the patient was transferred to a higher level of care.
Nitroglycerin 0.4 mg sublingual tablet was ordered PRN for chest pain. Patient received nitroglycerin 10 mg (entire 25 bottle dose) at one time. Patient’s blood pressure immediately dropped, and patient became lethargic requiring pressors and transfer to ICU [intensive care unit].
For safe dispensing and administration of sublingual nitroglycerin tablets, please consider the following safety strategies:
Create an alert in the automated dispensing cabinet (ADC)3 with instructions to dispense individual tablet(s) from the multidose bottle (e.g., “Warning: this is a multidose bottle. 1 tablet = 0.4 mg”).
Minimize distractions and multitasking during the medication selection and removal process from the ADC.3 Examine environmental factors such as lighting, noise level, and telephone interruptions.4
Instruct nurses to monitor patients for desired therapeutic effects and potential adverse effects following medication administration,4 and for the need to administer additional PRN doses.1
Explore various targeted opportunities that fit the needs and workflow of the
facility to educate healthcare providers about safe dispensing and administration of sublingual nitroglycerin tablets.
References
National Library of Medicine. Label: NITROSTAT - Nitroglycerin Tablet. Dailymed. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=79ba021e-183c-4b4d-822e- 4ff5ef54ca61. Updated February 28, 2018. Accessed October 2024.
Mayer GA. Instability of Nitroglycerin Tablets. Can Med Assoc J. 1974;110(7):788-9 passim. PubMed PMID: 4207612; PubMed Central PMCID: PMCPMC1947477
Institute for Safe Medication Practices. Guidelines for the Safe Use of Automated Dispensing Cabinets. ISMP; 2019.
National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to Enhance Accuracy of Administration of Medications. NCC MERP. https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications . Updated March 30, 2023. Accessed October 2024.
Reimagine Patient Safety 2029
The Patient Safety Authority (PSA) is excited to announce its ambitious new strategic plan, Reimagine Patient Safety 2029, with PSA’s vision of “safe healthcare for all patients” central to the plan’s three core goals summarized below:
Push the boundaries of information science: Harness existing and cutting- edge information science to identify and understand patient safety issues.
Leverage relationships: Collaborate with key stakeholders to implement impactful changes that improve patient safety.
Maintain a strong organizational culture: Prioritize people and continuous organizational improvement.
This comprehensive plan is the result of months of strategic planning, which included a thorough analysis of PSA’s strengths, opportunities, aspirations, and results (SOAR); insightful planning sessions with the Board of Directors, leadership, and staff; and valuable input from healthcare facilities and organizations across Pennsylvania.
On September 19, 2024, the PSA Board of Directors officially approved the plan for fiscal years 2025–2029, setting the stage for a transformative journey in patient safety.
Medication Errors
As part of a facility’s efforts to become a high reliability organization (which maintains high levels of safety, quality, and efficiency) to achieve zero patient harm, they turned
their attention to addressing reports of medication errors related to preparing intravenous
(IV) products. The standard practice at the root of the problem was that the preparer pulled back the syringe after completing the preparation to indicate the volume added, with no way to assure that the volume added agrees with the amount indicated in the pulled back syringe and that the correct amounts of each drug have been used during compounding.
They redesigned the pharmacy process, replacing the unreliable “pull back” method with an IV workflow system. The new process uses barcode scanning of ingredients to prevent errors prior to preparation and photographs of the individual ingredients and corresponding syringes that are used in the process to verify accuracy of the ingredients. Photographic documentation of the preparation process also assures the correct volume has been added, and IV products are scanned at the point of delivery to track individual products throughout preparation and delivery. The facility saw a statistically significant decrease in the number of reported preparation errors after implementing the new process, and all these reported errors involved situations in which the technology was bypassed.
