The
onset of a new school year renews the plight of head lice infestation.
Recently, concerns have focused on lice that are now resistant to
permethrin, the main chemical ingredient in many popular
over-the-counter lice products. Faced with this problem, lindane, a
prescription topical antiparasitic product, may be prescribed.
The USP Medication Errors Reporting (MER)
Program has received reports of dispensing errors where the liquid
topical product lindane has been accidentally mixed-up with various
other liquid products for oral administration. One recent error occurred
when a pharmacist filling individual bottles of lindane for several
family members became distracted by a technical problem. The lindane
stock bottle and the unlabeled prescriptions were left on the counter. A
subsequent prescription for a liquid cough preparation was mistakenly
filled with lindane. The same manufacturer produced both lindane and the
cough syrup, and although kept in different areas of the pharmacy, the
stock bottles reportedly looked similar. It is not, however, clear
whether the wrong stock bottle was used to fill the prescription or if
one of the unlabeled lindane bottles was labeled and dispensed as the
cough syrup. Unfortunately, the patient took one dose of the lindane and
experienced burning of the throat.
Two other medication errors received at USP
describe similar situations; in one report, a prescription for ferrous
sulfate elixir was filled with lindane. The prior prescription filled by
the pharmacist for lindane and the stock bottle had not been cleared
from the filling area. In the other report, a patient's wife recognized
that the odor from a bottle of an "antihistamine cough suppressant"
smelled like lindane. The product was confirmed as lindane.
Health care practitioners should be cautious to
institute a double check using the NDC number of the stock bottles.
Pharmacists should open medication bottles before dispensing but
especially when counseling patients as a final check in the dispensing
process. Additionally, clearing the filling area before dispensing a
new prescription may help prevent similar errors as this from occurring.
For more recommendations on strategies for avoiding error-prone aspects
of dispensing, see the National Coordinating Council for Medication
Error Reporting and Prevention's "Recommendations for Avoiding Error-Prone Aspects
of Dispensing Medications" .
