Alteplase dosing error


Intravenous products: The FDA state that in a recent report, the Institute for Safe Medication Practices warned about the possibility of prescribing and administering the wrong dose of alteplase when the indication for the drug is not specified.
ISMP described a case of a patient in an interventional radiology department who suffered respiratory arrest from a pulmonary embolism. The physician in charge of the radiology procedure called a code and requested Activase 100 mg IV. The pharmacist who responded to the code called the IV admixture staff and asked for tPA, or tissue plasminogen activator, a synonym for alteplase.
Because the call came from the radiology department, and because the prescribed dose and the intended use were not communicated, the pharmacy staff did not realize that the drug was intended to treat a pulmonary embolus. Instead, they assumed that the alteplase was intended to restore catheter function, so instead of the 100 mg dose that had been prescribed, they dispensed 2 mg of alteplase.
The physician running the code assumed the syringe he received contained the correct dose and administered it, which gave the patient a 50-fold underdose. The patient died, although it’s not clear what impact, if any, the medication error had on his death.
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