Multidose Nitroglycerin Bottles Associated With 25-Fold Overdose Errors

Strategies for safe dispensing and administration of nitroglycerin tablets to prevent an unintended overdose

By Myungsun Ro, PharmD, MS

The Patient Safety Authority has received multiple reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing erroneous dispensing and administration of whole bottle contents (up to 25 tablets) of sublingual nitroglycerin instead of a single tablet. As a result of these events, patients have required resuscitative measures and/or transfer to a higher level of care.

Sublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease.¹ The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air.² The loss of potency from environmental exposure² often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses prepackaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur.

Following are summaries of some of these events reported to PA-PSRS. 

Patient was ordered sublingual nitroglycerin for chest discomfort, and one bottle of sublingual nitroglycerin was retrieved from the ADC [automated dispensing cabinet]. The nurse scanned the barcodes on patient’s ID band and the medication bottle and administered all tablets in the bottle. A few minutes later, the patient called the nurses’ station and reported feeling sick. He was found to be hypotensive and diaphoretic, ultimately requiring resuscitation and transfer for increased monitoring.

PRN [i.e., prescribed “as needed”] sublingual nitroglycerin was ordered for a patient experiencing chest pain. After scanning the patient’s wristband and the bottle, the nurse administered the full bottle to the patient. The patient vomited and became hypotensive. A rapid response was called, fluids were administered, and the patient was transferred to a higher level of care.

Nitroglycerin 0.4 mg sublingual tablet was ordered PRN for chest pain. Patient received nitroglycerin 10 mg (entire 25 bottle dose) at one time. Patient’s blood pressure immediately dropped, and patient became lethargic requiring pressors and transfer to ICU [intensive care unit].

For safe dispensing and administration of sublingual nitroglycerin tablets, please consider the following safety strategies:



• Create an alert in the automated dispensing cabinet (ADC)³ with instructions to dispense individual tablet(s) from the multidose bottle (e.g., “Warning: this is a multidose bottle. 1 tablet = 0.4 mg”).
• Minimize distractions and multitasking during the medication selection and removal process from the ADC.³ Examine environmental factors such as lighting, noise level, and telephone interruptions.⁴
• Instruct nurses to monitor patients for desired therapeutic effects and potential adverse effects following medication administration,⁴ and for the need to administer additional PRN doses.¹
• Explore various targeted opportunities that fit the needs and workflow of the facility to educate healthcare providers about safe dispensing and administration of sublingual nitroglycerin tablets.

References

1. National Library of Medicine. Label: NITROSTAT - Nitroglycerin Tablet. Dailymed. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=79ba021e-183c-4b4d-822e-4ff5ef54ca61. Updated February 28, 2018. Accessed October 2024.
2. Mayer GA. Instability of Nitroglycerin Tablets. Can Med Assoc J. 1974;110(7):788-9 passim. PubMed PMID: 4207612; PubMed Central PMCID: PMCPMC1947477
3. Institute for Safe Medication Practices. Guidelines for the Safe Use of Automated Dispensing Cabinets. ISMP; 2019.
4. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to Enhance Accuracy of Administration of Medications. NCC MERP. https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications. Updated March 30, 2023. Accessed October 2024.

Reimagine Patient Safety 2029

The Patient Safety Authority (PSA) is excited to announce its ambitious new strategic plan, Reimagine Patient Safety 2029, with PSA’s vision of “safe healthcare for all patients” central to the plan’s three core goals summarized below:

1. Push the boundaries of information science: Harness existing and cutting-edge information science to identify and understand patient safety issues.
2. Leverage relationships: Collaborate with key stakeholders to implement impactful changes that improve patient safety.
3. Maintain a strong organizational culture: Prioritize people and continuous organizational improvement.

This comprehensive plan is the result of months of strategic planning, which included a thorough analysis of PSA’s strengths, opportunities, aspirations, and results (SOAR); insightful planning sessions with the Board of Directors, leadership, and staff; and valuable input from healthcare facilities and organizations across Pennsylvania.

On September 19, 2024, the PSA Board of Directors officially approved the plan for fiscal years 2025–2029, setting the stage for a transformative journey in patient safety.

Discover more about Reimagine Patient Safety 2029 at patientsafety.pa.gov (PDF).

Title: Nourishing Health Literacy: How to Serve Up Better Understanding

Date: Thursday, November 21, 2024

Time: 12 to 1 p.m.

Healthcare providers in Pennsylvania play an important role in ensuring patients have the knowledge they require to make informed decisions. Effectively communicating appropriate details while addressing each patient’s unique needs and concerns remains a challenge for both providers and patients.

The team will define health literacy, describe the scope and implications of the problem, identify the barriers that patients and providers have when trying to address low health literacy, and outline strategies to improve health literacy.

1.0 continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only.