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Controlled Drugs: Learning from Incidents - April 2024, Issue 27

Writer's picture: Mohammed A RashadMohammed A Rashad

Updated: Sep 9, 2024

  • Focus on local and national incidents to enhance shared learning

🚨 Recent CD Oral Liquid Incidents:


  • Morphine Oral Solution Incident:

  • Babies treated for overdose after being given 10mg/5ml instead of the prescribed 100 micrograms/ml.

  • The 100 micrograms/ml solution is classified as a 'RED DRUG – HOSPITAL ONLY DRUG' available as a 'specials' product.

  • Refer to the July 2023 alert on cdreporting.co.uk (Resource #107) for more details.

  • Clobazam Suspension Incident:

  • Label correctly indicated Clobazam 5mg/5ml but 10mg/5ml was dispensed due to a selection error.

  • Child received double the intended dose; error discovered during an unrelated hospital visit.

  • Gabapentin Oral Solution Incident:

  • Pharmacy received a prescription stating ‘Take 5ml (50mg) at night’, correct direction should have been ‘Take 1ml (50mg) at night’.

  • Pharmacist did not catch the prescribing error; patient continued with incorrect dosing without adverse effects.

💊 Best Practices for Pharmacies Handling CD Oral Solutions:


  • Clearly state the dose and volume per administration on dispensing labels.

  • During dispensing, verify the patient understands the correct dosage.

  • Provide appropriate measuring devices, like oral syringes.

  • Directly contact prescribers for queries on high-risk drugs or complex conditions.

  • Document all communications in the patient’s Pharmacy Medical Record (PMR).

🩺 Prescriber Guidelines:


  • Write dosages in micrograms for amounts less than 1 mg to avoid confusion.

  • Communicate directly with pharmacies for complex issues; record all notes clearly in patient files.

  • Include patient's weight and date of weighing on paediatric prescriptions.

  • Be vigilant with Specialised Red Drugs—prescribe only within secondary care settings.

References:

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