May 27, 2013: Another Mix-up Between Bisoprolol and Bisacodyl
A recent ISMP Canada Safety Bulletin reported on the potential for harm with mix-ups between bisoprolol and bisacodyl. Recently, ISMP Canada’s consumer reporting and learning program, SafeMedicationUse.ca, received a report about an elderly patient who received bisoprolol instead of bisacodyl from a community pharmacy. After taking the bisoprolol for 2 weeks, the patient experienced deterioration and was admitted to hospital with hypotension. Because a medication list (which listed bisacodyl, not bisoprolol) was brought to the hospital when the patient was admitted, the correct medications were administered during the hospital stay. The patient was treated, stabilized, and released after a hospital stay of almost 2 weeks. However, no one identified the medication error or realized that the patient had been taking bisoprolol at home.After returning home, the patient began taking the bisoprolol again. Several weeks later, the patient became weak and confused. At that time, a family member discovered the error. The family member who reported the incident believed that the original medication error was likely the cause of the hospital admission.
Several factors may have contributed to this incident:
Look-Alike / Sound-Alike Medications
The look-alike/sound-alike (LASA) property of the 2 medication names was almost certainly a factor contributing to the original medication error. A recent ISMP Canada Safety Bulletin highlighted medication errors, themes, and contributing factors related to this particular LASA pair and discussed recommendations for consideration, including review of storage areas for these drugs and examination of procurement practices in both acute care and community pharmacies.
Failure of the Medication Reconciliation Process
The overall aim of medication reconciliation is to ensure that communication about medications at all transitions of care is accurate and effective. Obtaining a Best Possible Medication History (BPMH) is the cornerstone of the medication reconciliation process. A BPMH is more comprehensive and more accurate than a primary medication list that does not use multiple sources of current information. The BPMH aids in making decisions that are based on accurate information because multiple reliable sources of information are used to create a snapshot of the medications the patient was taking at the time of transition. However, not all sources of information are considered equal. Generally, the most useful sources are the following:
• interview with patient or a caregiver
• medication vials or blister packs
• current medication list (i.e., from the pharmacy or provincial records)
In the case described above, the medication error might have been identified earlier if the medication vials had been examined at the time of the hospital admission or if the pharmacy’s records had been consulted.
