December 16, 2009: Medication Incident Involving Tamiflu (oseltamivir) at Transition of Care
ISMP Canada received a report about a school-aged child who inadvertently received Tamiflu (oseltamivir) 150 mg orally twice daily, instead of the appropriate weight-based dose of 60 mg twice daily, for the treatment of an H1N1 influenza-like illness. Tamiflu is an antiviral agent that has had a rapid increase in clinical use for the treatment of moderate to severe cases of pandemic H1N1 influenza and in situations where the patient is at risk of complications.In this case, the child had received 3 days of Tamiflu therapy in hospital, and a prescription written at discharge read “Tamiflu 2 capsules BID × 2 days”. The community pharmacist dispensed the 75 mg capsules, unaware that this drug is available in multiple strengths. A hospital pharmacist reviewing the discharge orders the day after discharge identified the risk for error, confirmed that an error had occurred (by viewing a provincial database), and contacted the community pharmacy. The community pharmacy in turn contacted the patient’s family to correct the situation, and the patient experienced no adverse effects.
This report is a reminder of the need to specify the exact medication dose in every prescription, as well as the need to assess the appropriateness of every medication during dispensing. It also shows exemplary follow-up on the part of the hospital pharmacist, and highlights the value of access to electronic health information along the continuum of care. ISMP Canada gratefully acknowledges the reporting practitioner for sharing information about this case to alert others of the potential for similar errors.
