ISMP Alerts

Cyclosporine Dispensing Errors

Almost 20 years ago, we published an article about SANDIMMUNE (cycloSPORINE capsules and oral solution) and how this non-modified form of the drug has decreased bioavailability compared to NEORAL or GENGRAF (cycloSPORINE [MODIFIED] capsules and oral solution). At the time, a survey by Novartis identified that 24% of prescriptions failed to specify which form of the drug should be dispensed, and only 22% of these prescriptions were clarified. We mention this because, 20 years later, we are still receiving reports of patients receiving SandIMMUNE when the prescriber’s preference was for a cycloSPORINE modified oral formulation. Three patients recently received SandIMMUNE instead of the more appropriate form of the drug, Neoral or Gengraf. In another case, during medication reconciliation, a nurse documented that a hospitalized patient was taking cycloSPORINE but did not verify the brand name to determine if it was the modified or regular form of the drug. The patient’s physician prescribed SandIMMUNE, and the patient received a dose before a pharmacy technician discovered that the patient had recently filled a prescription for Gengraf.

Because of the difference in formulation, these products are not interchangeable. Blood levels must be monitored to prevent serious consequences if a transplant patient receives the wrong formulation. Prescribers should indicate the brand name, and pharmacists should clarify prescriptions for cycloSPORINE. Order entry systems should clearly display these different forms of the drug, and a hard stop should force verification of the correct drug form during prescribing.

More Alerts

We recently learned about three cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia. Container mix-ups were involved in each case. In one case, a patient scheduled for knee surgery received tranexamic acid instead of
Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. For example, perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic physician order entry with decision support