Do Not Let “Depo-” Medications Be a Depot for Mistakes
Safe practice recommendations:
Today, the “Depo-” naming convention would be a concern for FDA based on its proprietary name review criteria (www.ismp.org/sc?id=423). However, when these drugs were first approved, the risk associated with this prefix was not considered. It would be very difficult to change the names of these products today—it may even make the risk of errors greater since these drug names are widely recognized. However, there are steps manufacturers, regulatory agencies, and healthcare practitioners can take to reduce the risk of potentially harmful mix-ups between these medications, strengths/container volumes, and routes of administration.
Manufacturers and regulatory agencies
Clarify labeling. Address the look-alike labels and packages of Depo-Testosterone as soon as possible. Most people look at the 1 mL and 10 mL vials and fail to realize that they are not the same.
Enhance warnings. Make warnings against IV use of depot products more prominent. The warnings should be clearly visible on the front label panel of cartons and vials, not on the back.
Healthcare practitioners
Keep vials apart. Separate the storage of Solu-MEDROL, Depo-Medrol, and Depo-Provera vials in the pharmacy and in all clinical settings where these drugs are stocked. Store only one medication in each bin or other storage container. Evaluate whether all three drugs need to be stocked in patient care units.
Differentiate the products. Consider stocking Depo-Provera in prefilled syringes for single patient use instead of single-dose vials. Depo-SubQ Provera 104 is available in single use 0.65 mL (104 mg) prefilled syringes for subcutaneous injections, and Depo-Provera 1 mL (150 mg) is available in prefilled syringes for intramuscular injections. Since Depo-Medrol is not supplied in prefilled syringes, this may increase differentiation between the two products, but only if staff know to expect Depo-Provera in a syringe. Thus, staff awareness is a necessary component of this differentiation strategy.
Limit access. Attempt to limit inventory of Depo-Testosterone to a single strength and vial size. Also evaluate which “Depo-” medications need to be stocked in patient care units, and limit access to those that can be dispensed as needed from the pharmacy.
Include auxiliary labels. Highlight or circle important information on labels to draw attention to it, or add an auxiliary label if necessary. For example, given the small font of the warning on Depo-Medrol vials, an auxiliary label that states, “IM Use Only” or “Intra-articular Use Only” may be required. For Depo-Testosterone labels, circle or point an arrow toward the total volume in each vial.
Express generic names safely. Use tall man letters when expressing the generic names of Depo-Medrol and Depo-Provera (i.e., methylPREDNISolone, medroxyPROGESTERone) to prevent confusion. When expressing generic names for Solu-MEDROL and Depo-Medrol, include the correct form of methylPREDNISolone (i.e., acetate, sodium succinate) to help differentiate the drugs.
Highlight the route. Always include the route of administration, easily visible in a prominent location, on orders and medication administration records.
Use barcode scanning. Implement barcode scanning to verify medications when stocking and restocking medications in automated dispensing cabinets, and prior to drug administration at the bedside as a method to help mitigate confusion that may lead to wrong drug medication errors. When used at the bedside, this technology confirms not only the drug but also the patient’s identity, dose, time, and dosage form of the medication being delivered. Track scanning compliance to ensure that staff is using the technology.
Increase staff awareness. Assess staff understanding of the term “depot,” and increase their understanding regarding why “Depo-” medications should not be administered IV. Be sure staff know the risk of confusion between “Depo-” products with similar names, such as mix-ups between Depo-Provera and Depo-Medrol, or the risk of errors related to labeling and packaging similarities with Depo-Testosterone.
This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, charitable nonprofit organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the March 24, 2016, issue of the ISMP Medication Safety Alert!