The Pharmaceutical Journal
Vol 272 No 7283 p76
24 January 2004

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FDA: Drug products associated with medication errors (more)

US safety alert over Keppra and Kaletra

A safety alert concerning the potential for dispensing errors arising from confusion between Keppra (levetiracetam) and Kaletra (lopinavir and ritonavir) has been issued to US health care professionals by the Food and Drug Administration.

The FDA alert comes after it received four reports of confusion between Keppra and Kaletra, one of which resulted in administration of the wrong drug to a patient. “The similarities between the names, in addition to the similarities in route of administration, dosage form and dosing quantity may further increase the risk of confusion between Keppra and Kaletra,” says the FDA.

FDA recommendations include:

• Educating health care staff about the potential for medication errors between these two products
• Verifying all orders between pharmacists and prescribers by spelling the proprietary name as well as the non-proprietary name
• Including the indications with the prescription when ordering either product
• Using computerised alerts when prescriptions are processed, as well as pharmacy shelf reminders

Kate Appleby, chief pharmacy technician for medicines management, Southern Derbyshire Acute Hospitals NHS Trust, told The Journal that medication errors arising from confusion between Keppra and Kaletra were not something she had come across. “However, we do have problems with similar named drugs.”

She explained that the trust was putting systems in place to ensure that when drugs are purchased, a risk assessment is performed. “We look at the packaging and drug name. We are also looking to assess where a medicine will sit on pharmacy shelves to identify potential problems.”

A spokesman for the Medicines and Healthcare products Regulatory Agency said that no yellow card reports of adverse events resulting from confusion between these two products had been received in the UK.

Issues raised by a new report on medication errors are discussed in a News feature on p80.