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Recordati Pharmaceuticals Limited has informed the MHRA of an error in the strength of the product printed on some of the faces (sides) of the product carton. The error is limited to one batch of Lercanidipine HCl 20mg Tablets. The packs are incorrectly labelled as 10mg on some sides of the product carton when they are 20mg tablets. Advice for Healthcare Professionals: Stop supplying the above batch immediately. Quarantine all stock and return it to your supplier using your supplier’s approved process. This medicine is being recalled as a precautionary measure. Pharmacists who have been supplied this batch and suspect they have dispensed the tablets to patients should contact the patient immediately to make them aware of this error. Please see ‘advice for patients’ section below. Advice for Patients: Patients who have been prescribed 10 mg tablets and have received tablets with this batch number (printed on the foil of the blister strips) should contact your pharmacist or GP immediately. In the event that the GP or pharmacist cannot be reached, please call NHS 111 for advice on continuing your medication. In the event you cannot speak to a healthcare professional before you are due to take your next dose: verify the strength of the tablets is 20 mg from the information on the foil of the blister strips remove one tablet from the blister as normal locate the break line on the tablet snap the tablet in half across the break line and take half of the tablet. This is permitted for the 20mg tablets and is in line with information included in the patient information leaflet (where it states ‘The tablet can be divided into equal doses’). Patients who have been prescribed 20 mg tablets should verify the strength of the tablets by checking the information on the foil of the blister strips prior to taking the tablet. Continue to take the tablets as prescribed by your doctor. Do not stop taking your medicine without consulting your healthcare provider. Patients who are concerned about the strength of the medication they have received should check it with their dispensing pharmacy. Patients concerned they may have accidentally taken a higher dose of the medication than they were prescribed should seek medical attention. Patients who experience adverse reactions or have any questions about the medication should seek medical attention. Any suspected adverse reactions should also be reported via the MHRA Yellow Card scheme. Additional information: For all medical information enquiries and information on this product, please email [email protected], or telephone +353 (0)87 6245669.

Medication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation.  Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub

A service providing bilingual medication information is helping to reduce healthcare inequalities and medical errors. Pharmacies across London are benefitting from the support of Written Medicine; a service providing bilingual dispensing labels in patients’ language of choice. Founded in 2012, Written Medicine’s software is used by pharmacies and hospitals to translate and print medication information, instructions and warnings. Drawn from a dataset of 3,500 phrases, printed labels are available in fifteen different languages. The bi-lingual labels are supporting patients to take ownership of their treatment; giving them a better understanding of how to take their prescribed medication. The solution is helping to reduce errors, improve medication adherence and enhance patient safety and experience. London North West University Healthcare NHS Trust (LNWH) has been using Written Medicine since 2016, starting from their outpatient pharmacy in Ealing Hospital. The Trust serves an ethnically and linguistically diverse demographic across North West London, which requires interpreting services in over 40 languages, mostly from South Asia, Middle East and Eastern Europe. An audit to assess the quality and impact of the bilingual labelling service at LNWH report in 2019 stated, “post-service questionnaire revealed all patients would like the continuation of the service by their community pharmacies demonstrating the impact it has had in patient empowerment and adherence.”. Poureya Aghakhani, Principal Pharmacist at Ealing Hospital, part of LNWH said, “Patients who are unable to speak English are less likely to understand their doctors, pharmacists and written instructions. This can stop them from taking their medication or may result in them taking it in an unhelpful or dangerous way. “Giving patients information in a language they understand increases awareness around how and when medication should be taken. It empowers individuals to take ownership of their treatment, improving how they manage their conditions and reduces their risk of harm."

This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023.  Valproate-containing medicines are used in epilepsy and bipolar disorder. There are known risks associated with valproate-containing medicines, including significant risks to children of mothers who took a valproate-containing medicine during pregnancy. Exposure of an unborn baby to valproate during pregnancy is associated with a high risk of congenital malformations (11%) and neurodevelopmental disorders (30–40%), which may lead to permanent disability. Following a consultation, the Government has put in place amendments to the Human Medicines Regulations 2012 (HMRs) to: require manufacturer’s original full pack dispensing of valproate-containing medicines enable pharmacists to supply up to 10% more than or less than the amount on a prescription of medicines other than those containing valproate, so that they can dispense a manufacturer’s original full pack instead of splitting the pack, known as original pack dispensing (OPD). This guidance provides information on the reasons for the change to dispensing of valproate-containing medicines (as above), and outlines what pharmacists need to do differently.

The existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant. This includes nonproprietary names and proprietary (brand or trade-marked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration, and the failure of manufacturers and regulatory authorities to recognise the potential for error and to conduct rigorous risk assessments for nonproprietary and brand names, prior to approving new product names This article from the WHO Collaborating Centre for Patient Safety Solutions looks at the issues and suggests actions.