Multidose nitroglycerin bottles associated with 25-fold overdose errors (15 November 2024)

Summary

Sublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease. The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air. The loss of potency from environmental exposure often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses pre-packaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur. This study examines reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing unintended dispensing and administration of whole bottle contents. These incidents have resulted in patients needing to be resuscitated and transfer to a higher level of care.