ALERT: Medicines Safety Group urgent announcements

The following information has been shared with CPSC by:

Andy Fox, Consultant Pharmacist Medicines Safety, Deputy Chief Pharmacist, University Hospital Southampton NHS Foundation Trust

Sulfadiazine / Sulfasalazine

UHS are aware of two incidents in the north of the area, as well as incidents within hospitals where these two medicines have been muddled up at their prescribing point when selecting them using the medicines drop-down box ↓.

Alerts have been added to GP systems on Sulfadiazine (the least commonly prescribed), to ask the prescriber if they really meant this product. On at least one previous occasion it was dispensed.

We would like to alert community pharmacists of this potential error and the need to question any prescription for Sulfadiazine to confirm that it was intended.

Colchicine

A Patient was admitted to UHS with Colchicine toxicity after receiving a prescription dispensed by their community pharmacist. The instructions on the label read “take 4 hourly”. The patient took four tablets every hour.

The Safety Group discussed labelling issues; particularly concerning prescribers use of 'free text' instructions in their systems and the subsequent copying of this at the pharmacy labelling stage of the dispensing process. Anecdotally labels stating “1 BD” and “2 TID” were also quoted as examples of this.

CPSC have suggested the Safety Group re-look at this important issue, but in the mean time we would like to remind all pharmacies to check that they are not leaving inappropriate dosage instructions on labels on EPS prescriptions.