Communicate alteplase dose and indication
From the August 28, 2008 issue
A patient who was undergoing a procedure in an interventional radiology department suffered respiratory arrest attributed to an acute pulmonary embolism. The physician in charge of the procedure called a code and requested ACTIVASE (alteplase) 100 mg IV. One of the pharmacists who attended the code called the central pharmacy’s IV additive service staff and asked for “tPA” (tissue plasminogen activator), a common but error-prone synonym for alteplase. Because the call came from the interventional radiology department, and the prescribed dose and intended use were not communicated, the pharmacy staff thought the medication was indicated for another use in the interventional radiology department, restoration of central venous catheter function. Thus, the pharmacy dispensed a 2 mg/2 mL syringe of CATHFLO ACTIVASE (alteplase; available in 2 mg lyophilized powder vials) instead of the 100 mg dose. The physician running the code, along with a myriad of physician residents in the room, assumed the dispensed syringe contained the correct dose to treat a pulmonary embolism and administered it. (The correct dose is 100 mg IV over 2 hours). Sadly, the patient died, although it’s unclear what impact, if any, the medication error had on his death. One potential source of confusion can be attributed to the fact that each product is available under the brand name Activase, although the catheter restoration product is named Cathflo Activase. Also confusing is the variable dosing for several labeled and off-label uses of alteplase, including coronary artery thrombi, acute ischemic stroke, acute pulmonary embolism, acute peripheral arterial occlusive disease, central venous catheter clearance, and even frostbite or pleural effusion. In non-urgent cases, using disease-specific protocols and order forms would reduce the possibility of errors. In emergencies, the purpose of the drug should be communicated with the order if disease-specific order sets cannot be used due to time constraints. Complete orders (i.e., dose, route, administration directions, in this case) should always be communicated, and pharmacy should not dispense medications without full prescribing information. Although it did not play a primary role in this error, alteplase should never be called tPA, as this abbreviation has been misunderstood and misread as TNKase (tenecteplase).