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Letters to the Editor
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Children's BNF
Near-miss error
From Dr C.F. Green, MRPharmS, and others
We wish to share the learning from a “near miss” patient
safety incident, which was contributed to by the layout and indexing
of the Children’s BNF 2007. In this near miss, a neonate was at
risk because of confusion between epoprostenol and dinoprostone.
A prescription was received in pharmacy requesting prostaglandin for
a neonate. The pharmacist dealing with the prescription looked up the
drug in the Children’s BNF, which gives two options, anticoagulant
or eye, but not ductus arteriosus, which was the reason prostaglandin
was being given to this infant. Eye was the least appropriate route,
so the pharmacist referred to the entry for anticoagulant on p148 (section
2.8.1).
On the page for anticoagulant, the only drug that is related to prostaglandin
is epoprostenol; alprostadil and dinoprostone are not mentioned at all.
Although the indication for anticoagulation is described, its use in
pulmonary hypertension is referred to in section 2.5.1.2.
Moving to section 2.5.1.2, the indication and dose for persistent pulmonary
hypertension of the newborn is listed. Unfortunately, the dose prescribed
for the neonate matched the dose range listed for epoprostenol as well
as the intended drug, dinoprostone.
The entry for prostaglandin in the main BNF is more helpful and lists
several clinical indications including ductus arteriosus. However, even
this would not have led to the intended drug, dinoprostone, being given
since the section referred to contains alprostadil but not dinoprostone.
Clarity about the indexing of prostaglandins in the BNFC is important
for prescribers and particularly for pharmacists who are only occasionally
requested to prepare the prostaglandin, dinoprostone, for infusion.
Dinoprostone is given to infants in an emergency when a ductus-arteriosus
dependent cardiac lesion is suspected. This is a temporary measure to
maintain ductal patency pending an urgent cardiac procedure to improve
oxygenation. Rarely, such a procedure is not feasible initially and an
infant may require a dinoprostone infusion until a cardiac procedure
can be performed later. It is in these uncommon circumstances that pharmacists
may be asked to prepare dinoprostone for infusion.
Clearly, there are a number of other issues that contributed to the error
and the incident could be described in classic ‘Swiss cheese’ modelling.
These issues are being addressed internally by the multidisciplinary
team members concerned. The role of the BNFC in this near miss could
be avoided if the index entry for prostaglandin listed epoprostenol,
dinoprostone and alprostadil and possibly a cautionary note about the
use of the term prostaglandin when prescribing or dispensing medicines.
If the clinical indications are to be listed under the index entry for
prostaglandin then it is important to include patency of the ductus arteriosus.
Chris Green
Director of Pharmacy and Medicines Management
Jos Wickett
Deputy Aseptic Services Manager
John Gibbs
Clinical Director, Women and Children’s Services
Countess of Chester NHS Foundation Trust
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SEJAL AMIN, staff editor, BNF Publications, replies: We are sorry
to hear about this medication near-miss.
A number of issues contributed to this incident. It is important that information
in BNFC is interpreted in the light of professional knowledge and supplemented
as necessary by specialised publications. The use of correct nomenclature is
of paramount importance in ensuring that the patient receives the right drug.
We are surprised that a prescription requesting prostaglandin for a neonate did
not set off more alarm bells. One would expect the actual drug required rather
than the drug class to be specified on the prescription. For example, indexing
under the term corticosteroids is considerable but one would not expect prednisolone
to be prescribed as corticosteroid on the prescription. Also, one might expect
a slightly different sequence of events to determine the intentions of the prescriber.
Dr Green’s feedback is valuable and appreciated. We will, of course, review
the indexing of these terms and make improvements wherever possible.
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