We have published cases of medications dispensed before they were reconstituted, particularly unmixed antibiotics.
We have published cases of medications dispensed before they were reconstituted, particularly unmixed antibiotics. Most cases involved pediatric patients who received overdoses when their parents administered the unreconstituted drug powder. Unfortunately, the pharmacy staff involved had failed to reconstitute the antibiotics before dispensing them to the patients or caregivers.
However, the Institute for Safe Medication Practices also has received reports from customers about inappropriately mixed oral suspensions. Most often, not enough diluent was used to reconsti- tute the medication powder. For example, a mother noticed that her son’s Quillivant XR (methylphenidate extended release) suspension was much more viscous than usual. The bottle was only half full, and it was obvious that it held much less fluid than even the 158 mL of water required for reconstitution of the Quillivant XR 900 mg bottle.
In another case, a 3-year-old girl was prescribed cephalexin oral suspension for 10 days. Her mother followed the dosing instructions printed on the pharmacy label but on day 7 ran out of the antibiotic. It was suspected that the incorrect amount of diluent had been used to reconstitute the antibiotic. To make matters worse, when the mother reported the potential error to the pharmacist, instead of acknowledging that the product may have been reconstituted incorrectly, he accused her of spilling the medication.
Inappropriately reconstituted medications, particularly antibiotics, can lead to adverse effects, including both underdoses and overdoses and treatment failures. It is critical that pharmacies examine their processes for reconstituting medications and take steps to reduce the risk of errors.
Consider the following risk-reduction strategies:
Michael J. Gaunt, Pharm D, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.