Double check concentration of compounded medication suspensions before dispensing

October 7, 2014

It is important to remember that when compounding medications, recipes for more than one concentration may be available.  Mix ups in the concentration can lead to dosing errors, which can result in significant adverse effects for patients. Two recent incidents with baclofen brought this lesson to light.

Prescriptions for compounded suspensions or solutions carry an increased risk of dosing error because the concentration dispensed may change from one prescription or refill to the next. For example, drugs such as baclofen can be compounded in numerous concentrations including 1, 5 or 10 mg/mL. The concentration dictates the volume per dose, and therefore should be confirmed with both the prescriber and the patient (or caregiver, in the case of pediatric patients) to avoid over- or under-dosing the medication.

The standards require pharmacists to ensure the prescription is filled correctly, in accordance with the prescription.  Double check the dose and concentration of the medication before dispensing. 

The standards require pharmacists to confirm dosing instructions before releasing a prescription, even if the patient has received the medication before.

The patient or their caregiver must be provided with instructions on appropriate dosing of medications. This is especially important for medications dispensed as a suspension or solution, as dosing volume will vary, depending on the medication concentration.

Standards reference

The Standards of Practice for Pharmacists and Pharmacy Technicians state:

7.1       A pharmacist or a pharmacy technician who dispenses a drug or blood product must ensure that:

  1. the drug or blood product is correct and in accordance with the prescription; and
  2. the dosage form, strength, manufacturer and quantity dispensed are correct and in accordance with the prescription.

8.5       The pharmacist must:

  1. focus the dialogue on the particular patient’s condition and needs,
  2. assess the patient’s level of understanding, and
  3. endeavor to respond to the patient at the appropriate level.

Originally published in the October 7, 2014 issue of The Link


← Previous ArticleNext Article →