A not-so-simple swap: Patient counselling highlighted potential for error when changing multi-ingredient products

Due to the lack of availability of some medications, insurance coverage restrictions, or specific patient requests, pharmacists are occasionally required to change the strength of a medication prescribed and the instructions for use.However, pharmacists must be aware of the potential for error when changing multi-ingredient drug products.IncidentA prescription for Clavulin® 875 mg with the instructions for use as one tablet twice daily for seven days, was taken to a community pharmacy and presented to a pharmacy assistant for processing.The prescription was processed accurately as Apo-Amoxi Clav 875/125.However, during patient counselling, the patient observed the size of the tablets and asked whether it was possible to get tablets that are smaller in size.The pharmacist explained that due to the dose of 875 mg, the patient would need to take three and a half of the smaller 250 mg tablets twice daily.The patient responded that they would be willing to take three and a half of the 250 mg tablets twice daily because they are unable to swallow the large 875 mg tablets.The pharmacist therefore made the decision to make the change to Apo-Amoxi Clav 250/125.However, the pharmacist failed to note that three and a half Apo-Amoxi Clav 250/125 tablets are not equivalent to one Apo-Amoxi Clav 875/125 tablet.Though they both contain 875 mg Amoxicillin, one Apo-Amoxi Clav 875/125 tablet contains 125 mg of clavulanic acid, while three and a half Apo-Amoxi Clav 250/125 tablets contain 437.5 mg of clavulanic acid or three and a half times as much.The patient would therefore consume 875 mg Clavulanic Acid each day with the potential for serious gastrointestinal side effects.Fortunately, the pharmacist identified the error while counselling the patient on the Apo-Amoxi Clav 250/125 tablets.The patient was therefore offered and consented to receiving Clavulin® - 400 oral suspension which is the most appropriate Clavulin® preparation to maintain the same Amoxicillin/Clavulanic Acid ratio.Please see table below:ProductContentDrug Ratio Clavulin®-125F oral suspensionEach 5ml oral suspension contains 125 mg of amoxicillin and 31.25mg of clavulanic acid 4:1Clavulin®-250F oral suspensionEach 5ml oral suspension contains 250 mg of amoxicillin and 62.5mg of clavulanic acid 4:1Clavulin®-200 oral suspensionEach 5ml oral suspension contains 200 mg of amoxicillin and 28.5mg of clavulanic acid 7:1Clavulin®-400 oral suspensionEach 5ml oral suspension contains 400 mg of amoxicillin and 57mg of clavulanic acid 7:1Clavulin®-250 tabletsEach tablet contains 250 mg amoxicillin and 125mg of clavulanic acid 2:1Clavulin®-500F tabletsEach tablet contains 500 mg amoxicillin and 125 mg of clavulanic acid 4:1Clavulin®-875 tabletsEach tablet contains 875 mg amoxicillin and 125 mg of clavulanic acid 7:1Recommendations:Be aware of and educate all pharmacy staff about the various drug combinations contained in Clavulin® products and the potential for error when changing the strength and instructions for use.Note that:Two Clavulin®-250 tablets are not equivalent to one Clavulin®-500F tablet. Five milliliters of Clavulin®-250F oral suspension are not equivalent to one Clavulin®-250 tablet.Clavulin®-125F and Clavulin®-250F oral suspensions are stable under refrigeration for 10 days after reconstitution. However, Clavulin®-200 and Clavulin®-400 oral suspensions must be used within seven days after reconstitution. As a result, a 10-day supply of Clavulin®-200 and Clavulin®-400 cannot be dispensed at once.Maintain a list of these products and share this information with all pharmacy staff. Other similar products include:DrugContent per unit doseAdvair® 250 Diskus Advair® 500 Diskus 250 mcg fluticasone propionate and 50 mcg salmeterol500 mcg fluticasone propionate and 50 mcg salmeterolAdvair 125® InhalerAdvair 250® Inhaler125 mcg fluticasone propionate and 25 mcg salmeterol250 mcg fluticasone propionate and 25 mcg salmeterolSymbicort® 100 TurbuhalerSymbicort® 200 Turbuhaler 100 mcg budesonide and 6 mcg fomoterol fumarate dihydrate200 mcg budesonide and 6 mcg fomoterol fumarate dihydrateNote that one dose of an Advair® 250 Inhaler is not the same as one dose of an Advair® 250 Diskus.Please continue to send reports of medication errors in confidence to Ian Stewart at ian.stewart2@rogers.com for possible publishing in a future Lessons in Error Prevention article. Sharing your experience can prevent similar occurrences at other practice sites.Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.

A not-so-simple swap: Patient counselling highlighted potential for error when changing multi-ingredient products

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