Safe Prescribing
Confusion seems to reign whenever a drug is available in oral forms with different release rates. And, when two or more delayed-release forms exist for the same product, the confusion doubles. The ISMP has learned of four cases where pharmacists dispensed Metadate ER instead of Metadate CD. Although both drugs are extended-release formulations of methylphenidate hydrochloride, they aren't substitutable.
The CD product, a daily capsule with biphasic release, provides an initial rapid release of methylphenidate, then a continuous release phase, resulting in daylong control of attention deficit hyperactivity disorder symptoms. The ER product, a tablet, is given b.i.d. to t.i.d. None of the pharmacists involved in the error knew
The authors of Safe Prescribing are the following staff from the Institute for Safe Medication Practices (ISMP): Hedy Cohen, RN, BSN, vice-president nursing; Judy Smetzer, RN, BSN, director, risk management; and Michael Cohen, RPh, MS, FASHP, president ISMP, a nonprofit organization, derives its reports from the USP Medication Errors Reporting Program. To report medication errors, call the USP at 1-800-23-ERROR (233-7767). To contact ISMP, call 215-947-7797 or e-mail ismpinfo@ismp.org.
Copyright Springhouse Corporation Aug 2002
Provided by ProQuest Information and Learning Company. All rights Reserved
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