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Topical Lindane Prescriptions Confused with Oral Liquid Prescriptions

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" .

Readers are advised that official USP cautions and warnings for drugs appear in the USP-NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice.

© 1997 - 2002 The United States Pharmacopeial Convention, Inc.



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