August 2009: Report of Incorrect Glucose Tolerance Testing Product Received and Administered
A healthcare organization received bottles of glucose solution containing 75 grams of glucose, rather than solutions containing 100 grams of glucose as ordered from the distributor. The following information is shared:A laboratory staff member was preparing to carry out a glucose tolerance test for an adult patient. Upon retrieving the glucose beverage, the staff member noticed that the incorrect strength was stocked. The organization always purchased and stocked only bottles containing 100 gram of glucose solution; laboratory staff members then gave each adult patient the amount of beverage required for the specified dose, according to the glucose tolerance test to be done. The product distributor confirmed that the incorrect product had been shipped, and an inventory count indicated that the product had been in use for about 10 days. The organization contacted 30 patients who might have received an incorrect dose, and retesting was recommended for 19 of these patients.
The organization is now conducting a review to determine underlying causes of the error. Preliminary information suggests that labelling and packaging may have played a part, since the 50 gram, 75 gram, and 100 gram doses are packaged in the same size of bottle, with similar labels (Figure 1).
Figure 1: Three products of orange-flavoured Trutol available from the manufacturer (from left to right, bottles containing 100 grams, 75 grams, and 50 grams), atop their respective shipping cartons. The bottles, which are identical in size, all contain an orange liquid. The labels for all 3 products have a white background with blue and red print, the red print specifying the product name and dose.
Ultimately, an automated checking system, such as bar coding, at all stages of the process (ordering, shipping, receiving, stocking, and administration) may assist in preventing such incidents. In the interim, ISMP Canada suggests that healthcare organizations and professionals review their procedures for glucose tolerance testing and for managing oral glucose beverages to ensure that, in addition to the name and strength of the solution, the product number is double-checked against the purchase order and inventory requirement.
ISMP Canada has informed the manufacturer and Health Canada of this report.
