In coming days, authorities from the Ministry of Public Health will convene pharmaceutical industry representatives who manufacture medications for pediatric use. The goal will be to define a new labeling system that allows those medications with similar commercial presentation to be identified and distinguished. The decision was made following numerous cases involving the erroneous administration of medications.
General Director of Health Jorge Quian reported that conversations will be held with the Patient Safety Commission (Comisión de Seguridad del Paciente or Cosepa) and with the pharmaceutical laboratories “to seek that these [medications] contain a special mechanism, a notification on the box,” he stated.
The official added that the appeal to the laboratories “is an innovation” in response to the concern over errors in the administration of medications and the need to adopt preventive measures.
Risky confusion
Due to an error in the dispensation of Mulsiferol 100,000 UI/10 ml — vitamin D3 — at the Hospital Saint Bois pharmacy, 233 children received an overdose of the medication intended for adults, which in some cases led to their hospitalization.
According to a report by the State Health Services Administration (Administración de los Servicios de Salud del Estado or ASSE), the health facility did not purchase the children’s version of the calcium-fixation vitamin D3 complex for four months (March, April, May, and June) this year, supplying the one indicated for adult patients instead.
Quian indicated that in this particular case, Mulsiferol is packaged in a way that is very similar to Viosterol. “The Academy guidelines in which I myself participated when I was a professor at the School of Medicine states: Mulsiferol eight drops and Viosterol eight drops.”
The medication intended for children was Mulsiferol in drops, not in an emulsion form as provided by pharmacy staff to the patients. In this case, neither the health facility staff nor the parents or guardians of the children were able to distinguish the medications due to the similarity in the esthetic characteristics of their packaging.
Consequently, of the children who received the incorrect medication, 26 presented high levels of calcium in their blood (hypercalcemia), four of whom remain hospitalized — one of whom has nephrosclerosis, which is the presence of calcium in the kidneys — and 73 of whom received outpatient care.