ISMP warns about mislabeled IV bag overwraps

A mislabeled overwrap and a difference of two lowercase letters on an intravenous bag have prompted a national alert after a nurse administered the medication and, 15 minutes later, the patient's heart rate slowed. 

The Institute for Safe Medication Practices said a Hikma Pharmaceuticals lot 24070381 might contain a dexmedeTOMidine 400 micrograms per 100 milliliters infusion bag with Canadian labeling and a different font than U.S. labeling and capitalization, which is dexmedeTOMIDine. The product's overwrap is labeled for acetaminophen injection 1,000 milligrams per 100 milliliters. 

A nurse reported to the ISMP that she removed what was thought to be an acetaminophen injection bag from an automated dispensing cabinet, scanned the barcode on the overwrap and administered the infusion. About 15 minutes later, the patient experienced bradycardia and bradypnea. 

The empty bag on the IV pole was labeled as dexmedeTOMidine hydrochloride injection. The nurse contacted the physician, and the patient received supplemental oxygen and recovered. 

A spokesperson for Himka told Becker's the company is aware of the single incident and immediately began an investigation. The company has also told affected customers to place the products in quarantine, and it is initiating a recall. 

"While this is an unusual situation, ISMP recommends scanning the barcode directly on an infusion bag, not the overwrap, prior to administration," ISMP President Rita Jew, PharmD, said in a news release shared with Becker's. "Healthcare practitioners should be vigilant in checking the actual infusion bag for Hikma's acetaminophen injection label, regardless of the lot."

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