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Watch out for these three common errors with diabetes medications

Because managing diabetes is complex, there is more of an opportunity for mistakes with these medications. 
6/12/2023

While prescribing diabetes medication is quite common, managing diabetes is complex, leaving as on outsized number of opportunities for mistakes. 

A new bulletin from the Institute for Safe Medication Practices Canada looked at 441 incidents with newer oral and subcutaneous injectable agents, DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists. (It excluded drugs used off-label for weight loss.) 

Jardiance (empagliflozin) was most likely to be involved in these issues, followed by Ozempic (semaglutide), Janumet (sitagliptin/metformin), Janumet XR (sitagliptin/metformin, modified release) and Forxiga (dapagliflozin). 

The errors fell under three categories: complex medication regimens, look-alike or sound-alike names, and product packaging and storage.

Read: Finding your Niche: Making an impact in diabetes care

Complex medication regimens

Complex medication regimens sometimes led to errors when an existing pharmacy file was copied to create a new prescription entry. As a result, the ISMP recommends only using the copy function if the prescriptions are unchanged. It also recommends prescribers prominently note dose changes and the medication on the prescriptions.

Further, pharmacists should always ask the patient or caregiver about glucose management and the antidiabetic medications/doses they’re on—and inactivate prescriptions for old drugs and doses. 

Dose titration can also be tricky. In one example, a patient brought in a prescription for a titrating semaglutide dose that was to be placed on hold and used later. Still, the pharmacy staff only entered the first part of the regimen into their system, as they didn’t realize that multiple steps and various products would be used. They identified and corrected the error later. 

Other reports said patients mistakenly kept taking a starting dose because the refill label contained instructions for the initial starting dose by mistake. 

To help patients understand complex titration schedules, the ISMP recommends offering each titration step as a separate prescription so that patients can be counseled at each stage. If it is registered as one prescription that can be refilled instead, the system should include a flag to make sure that the pharmacist talks to the patients every time the dose changes.

It also recommend numbering each step in the titration for clarity and creating a calendar that explains the dosing titration, giving one copy to the patient and scanning a document into the prescription file. 

In addition, now knowing about the proper dosing frequency of medications has been a commonly found in incidents, such as not knowing the difference between immediate-release and modified-release formulations and not being aware of the range of dosing regimens in injectable medications in the GLP-1 receptor agonist class. To counter this, pharmacies should make educational materials available to pharmacy staff that cover new medication formulations and dosing regimens available for quick reference.

Read: Rush for diabetes and weight loss drug Ozempic puts cross border sales in spotlight

Look-alike and sound-alike names

Pharmacists reported incident reports with medications with similar names or packaging when prescribing, entering orders and preparing drugs. That included confusion around multiple strengths and concentrations, combination products, modified formulations—and confusion with medications that weren’t for diabetes. 

Examples that were confused include brand names like Janumet, Januvia and Jardiance, and generic names like canagliflozin, dapagliflozin and empagliflozin. Similar packaging also led to medication errors. 

To prevent these, the ISMP recommended separating medications that look alike with a shelf divider or putting them into separate bins and including scanning barcodes into pharmacy processes like dispensing and managing inventory. It also recommended encouraging prescribers to note both the brand name and generic name in prescriptions, to emphasize the distinctions between products on the hard copy of the prescription during verification, and to work with software vendors or IT to make critical information more prominent in software. 

Read: ISMP analysis highlights errors that can happen with look-alike high-alert medications

Multiple Pack Sizes and Dose Delivery Options

Another error highlighted was when products were dispensed in the incorrect quantity because a similar product with a different dose was dispensed instead. For example, a prescription for liraglutide (Victoza) 1.2 mg once daily for 90 days was filled with one box of three pens. But since each pen delivers 15 doses of 1.2 mg, the patient needed six pens, or two boxes. The pharmacist found the error and corrected the quantity before dispensing it to the patient.

It can be confusing because liraglutide is available in a multidose pen that can deliver doses of 0.6 mg, 1.2 mg, or 1.8 mg, and the pens come in packs of one, two or three pens. Other drugs are also available in pens that come in different doses. 

To prevent mistakes, the ISMP recommends adding an independent double check of dose and quantity into the dispensing process and creating quick-reference materials staff can use on product pack sizes and dose delivery options.

Finally, another common error was grabbing the wrong patient’s prescription from the fridge, where medications are stored after a prescription is filled and before it’s given to the patient. To prevent this, organizing the prescriptions alphabetically by patient name can help, as can making sure the patient’s name is visible on the filled prescription in the fridge. 

Read: ISMP course helps pharmacists avoid medication incidents in kids

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