An incident at an outpatient pharmacy led to a patient receiving the wrong dosage strength of traZODone due to a transcription error. The e-prescription, intended for “traZODone HCl 50 mg oral tablet, take one to two tabs at bedtime,” was misinterpreted by a pharmacy technician who confused the lowercase letter “l” in “HCl” for the numeral “1.” As a result, the prescription was processed as traZODone 150 mg tablets. The patient took this incorrect dose for 90 days before another technician identified the discrepancy during a refill.
The pharmacy quickly informed both the patient and prescriber about the error. No harm was reported from taking the higher dose. The underlying cause appeared to be an issue with how the e-prescription populated in the pharmacy’s system, requiring manual entry of dosage strength.
Drug names ending with "l" have been linked to overdose incidents when there is not enough space between the drug name and its strength on prescriptions. This problem can occur with handwritten prescriptions and also affects electronic ones if spacing is inadequate.
In this case, including "HCl" (hydrochloride) in the drug name contributed to confusion. According to ISMP’s recently updated Guidelines for Safe Electronic Communication of Medication Information, chemical salts like "HCl" should be omitted from generic drug names unless multiple salts exist or it impacts drug release properties. Since traZODone is only available as hydrochloride salt, omitting "HCl" could help prevent similar errors.
The informatics administrator for the prescriber stated that their system could not remove "HCl" from drug names. To reduce manual transcription needs and potential errors, healthcare providers are advised to ensure e-prescriptions meet standards established by organizations such as the National Council for Prescription Drug Programs and Surescripts. Pharmacies are encouraged to test and update their systems regularly for accurate processing of e-prescriptions.
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