Preventing medication errors with immunologic drugs

Learning Objectives for this Presentation:
Learning objectives: By the end of the presentation participants will be able to:
1. Describe common causes of product-related medication errors with immunologics
2. Recognize factors that lead to confusion because of look-alike names, labeling and packaging of immunologics.
3. Recognize how certain dangerous dosage unit designations, confusing drug names, and drug name abbreviations, suffixes and acronyms may contribute to medication errors.

Background:
Background:
Improper immunization presents risks to human health such as vulnerability to a preventable infection or, in a worst case scenario, serious patient injury when certain non-vaccine products are inadvertently confused with a vaccine. In recent years, public health officials have become familiar with outbreaks of medication errors where practitioners selected and administered the wrong product. As examples, multiple reports have been received by the national USP-ISMP Medication Errors Reporting Program involving confusion between pediatric-strength diphtheria–tetanus toxoids and adult-strength tetanus–diphtheria toxoids. Also, CDC, FDA and ISMP have issued alerts about administration of tetanus toxoid instead of purified protein derivative, which in some cases led to improper treatment with isoniazid for a "positive" skin test. No single factor can be identified as the cause of these mix-ups. However, a frequent contributor to errors with immunologics relates to product name similarity, and package design that does not clearly distinguish various products or communicate dosages in a safe manner.

Setting:
Various public health settings, regulatory authorities, dispensing pharmacies, clinical environment, product manufacturers in pharmaceutical and biological industry.

Population:
Population:
Manufacturers, healthcare practitioners, and all patients who receive immunologics.

Project Description:
Project description:
The authors will review specific product-related issues that contribute to medication errors and offer strategies for adoption by the government, regulatory authorities, and industry to address what is becoming an all too frequent public health concern.

Results/Lessons Learned:
Manufacturers, public health pfficials and practitioners will learn common product-related causes of medication errors with immunologics