Do Not Let “Depo-” Medications Be a Depot for Mistakes

NSO and the Institute for Safe Medication Practices (ISMP) have teamed up to help you practice safe medication use and keep patients safe. The following is an ISMP Medication Safety Alert from the May 2017 NSO Risk Advisor.

Several medications are available on the market with names that begin with the prefix “Depo-,” meaning they are administered via a depot injection that deposits the drug into localized tissue from which it is gradually absorbed by surrounding tissue. These injections, typically subcutaneous, intramuscular (IM), or intra-articular, allow the active compound to be released consistently over a longer period of time. Many of these medications with the prefix “Depo-” have been on the market for 30 to 50 years, some even longer. Misadministration of these medications and confusing one “Depo-” medication with another has been consistently reported throughout the years. More recently, mix-ups between different strengths and volumes of containers of a “Depo-” drug have occurred. The “Depo-” medications most often involved in outpatient wrong route, wrong drug, or wrong strength/volume errors can be found in Table 1.
 
Table 1. “Depo-” medications most often involved in outpatient medication errors.
  
Brand Name Generic Name Route Description
Depo-Provera
 
Depo-Provera Contraceptive Injection
 
Depo-SubQ Provera 104
medroxyPROGESTERone acetate IM
 
Subcutaneous
A progestin used as a contraceptive, or to
treat endometriosis or endometrial carcinoma
Depo-Medrol methylPREDNISolone acetate IM
 
Intra-articular
An anti-inflammatory or immunosuppressive
corticosteroid
Depo-Testosterone testosterone cypionate IM An androgen used to treat male hypogonadism
 
Examples of error reports submitted to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and/or the ISMP National Medication Errors Reporting Program (MERP) are provided below.
 

Depo-Provera vs. Depo-Medrol

In early 2015, FAERS received a report involving a 44-year-old man with shoulder pain (non-impingement) who received an intra-articular injection of Depo-Provera instead of Depo-Medrol. A box of Depo-Provera had been stored inadvertently in the bin where Depo-Medrol was usually kept in a medication cabinet. Other than size, the medication cartons do not look similar, but both drug names start with “Depo-…” and appear in the same black font (Figure 1). The physician performing the shoulder injection reached into the bin and removed a box of the correct medication, Depo-Medrol, and read the label and concentration. He set that carton aside, and a moment later, he inadvertently reached back into the bin and removed another box, but this one contained Depo-Provera. Believing he had previously confirmed the drug and concentration, the physician withdrew the desired amount of an opaque white liquid similar in appearance to Depo-Medrol (Figure 2). The physician injected about three-quarters of the 1 mL volume he had withdrawn into the syringe (about 112 mg of Depo-Provera). A medical assistant discovered the error while cleaning up after the patient had left the office. Within 3 days of the injection, the patient experienced a lack of libido and had erectile dysfunction, which required prolonged use of testosterone and CIALIS (tadalafil). Since making the error, the physician learned that others have made the same error, mixing up Depo-Medrol and Depo-Provera.
 

Depo-Medrol vs. Depo-Provera

Several years ago, ISMP received a report of a similar mix-up, again leading to patient harm, but in this case, the patient was supposed to receive Depo-Provera but received Depo-Medrol in error. A 19-year-old woman went to a clinic to receive an injection of Depo-Provera for contraception, which was to be repeated every 12 weeks. After providing a negative pregnancy test, the young woman was mistakenly given an intramuscular injection of Depo-Medrol. The lot number of the vial of medication was recorded in her medical record. The woman returned in 12 weeks and reported a positive home pregnancy test. An ultrasound confirmed the pregnancy, with an estimated date of conception about 3½ weeks after her first injection. The error was uncovered when the documented lot number was found to be associated with Depo-Medrol.
 
In this case, Depo-Medrol and Depo-Provera had previously been stored in separate cabinets. However, a few days before the event, the medication cabinets had been consolidated, and the medications were stored alphabetically in bins. The stock in the consolidated cabinet had been labeled with Depo-Provera and Depo-Medrol, which were stored next to each other. Working with only a verbal order for the drug, the clinic staff had accidentally selected a vial of Depo-Medrol instead of the intended Depo-Provera. 
 

Wrong strength Depo-Testosterone

ISMP has received reports regarding potential errors with Depo-Testosterone for which the wrong strength or volume of the drug might be administered to patients. This drug is available in two strengths: 100 mg/mL and 200 mg/mL. The 200 mg/mL strength is available in a 1 mL vial and a 10 mL vial. However, the vial sizes are extremely hard to differentiate when looking at the medication cartons (Figure 3).
 

Wrong route Depo-Medrol

In late 2015, a patient received 100 mg of Depo-Medrol IV. The route of administration was not specified on the written order given to the nurse, who assumed the drug should be administered IV, like the other medications the patient was receiving. The nurse did not recall seeing the statement, “Not for IV Use” on the back of the vial label; the statement is in a very small font size. Fortunately, the patient was not harmed. The reporting pharmacist found many case reports of similar errors published in the literature.
 
Other errors involving Depo-Medrol being administered IV instead of intramuscularly have resulted from mix-ups between SOLU-MEDROL (methylPREDNISolone sodium succinate) and Depo-Medrol, often due to stocking errors. Depo-Medrol’s milky white appearance rarely gives pause anymore before administration given the wide variety of other cloudy or opaque medications that are administered IV.
 

Safe Practice Recommendations

While we have suggested specific label enhancements to manufacturers, until label changes happen, consider the following recommendations to reduce the risk of potentially harmful mix-ups between these medications, strengths/container volumes, and routes of administration.
 
Keep vials apart. Separate the storage of Solu-MEDROL, Depo-Medrol, and Depo-Provera vials in the pharmacy and in all clinical settings where these drugs are stocked. Store only one medication in each bin or other storage container. Evaluate whether all three drugs need to be stocked in patient care units.
 
Differentiate products. Ask pharmacy to consider stocking Depo-Provera in prefilled syringes for single patient use instead of single-dose vials. Depo-SubQ Provera 104 is available in single use 0.65 mL (104 mg) prefilled syringes for subcutaneous injections, and Depo-Provera 1 mL (150 mg) is available in prefilled syringes for intramuscular injections. Since Depo-Medrol is not supplied in prefilled syringes, this may increase differentiation between the two products, but only if staff know to expect Depo-Provera in a syringe. Thus, staff awareness is a necessary component of this differentiation strategy.
 
Limit access. Attempt to limit inventory of Depo-Testosterone to a single strength and vial size. Also evaluate which “Depo-” medications need to be stocked in patient care units, and limit access to those that can be dispensed as needed from the pharmacy.
 
Include auxiliary labels. Highlight or circle important information on labels to draw attention to it, or add an auxiliary label if necessary. For example, given the small font of the warning on Depo-Medrol vials, an auxiliary label that states, “IM Use Only” or “Intra-articular Use Only” may be required. For Depo-Testosterone labels, circle or point an arrow toward the total volume in each vial.
 
Express generic names safely. Use tall man letters when expressing the generic names of Depo-Medrol and Depo-Provera (i.e., methylPREDNISolone, medroxyPROGESTERone) to prevent confusion. When expressing generic names for Solu-MEDROL and Depo-Medrol, include the correct form of methylPREDNISolone (i.e., acetate, sodium succinate) to help differentiate the drugs.
 
Highlight the route. Always include the route of administration, easily visible in a prominent location, on orders and medication administration records.
 
Use barcode scanning. Implement barcode scanning to verify medications when stocking and restocking medications in automated dispensing cabinets, and prior to drug administration at the bedside as a method to help mitigate confusion that may lead to wrong drug medication errors. When used at the bedside, this technology confirms not only the drug but also the patient’s identity, dose, time, and dosage form of the medication being delivered. Track scanning compliance to ensure that staff is using the technology.
 
Increase staff awareness. Assess staff understanding of the term “depot,” and increase their understanding regarding why “Depo-” medications should not be administered IV. Be sure staff know the risk of confusion between “Depo-” products with similar names, such as mix-ups between Depo-Provera and Depo-Medrol, or the risk of errors related to labeling and packaging similarities with Depo-Testosterone.
 
Both “Depo“ products have been mixed up, despite dissimilar carton labels.
Figure 1. Both “Depo“ products have been mixed up, despite dissimilar carton labels.
 
Vials look dissimilar except for the “Depo-“ part of the drug name and the opaque white liquid inside the vial.
Figure 2. Vials look dissimilar except for the “Depo-“ part of the drug name and the opaque white liquid inside the vial.
 
Can you see the difference? The labeling on cartons of Depo-Testosterone make it hard to notice that one contains a 1 mL vial (L) and the other (R) contains a 10 mL vial. The same is true with the 100 mg/mL strength vials.
Figure 3. Can you see the difference? The labeling on cartons of Depo-Testosterone make it hard to notice that one contains a 1 mL vial (L) and the other (R) contains a 10 mL vial. The same is true with the 100 mg/mL strength vials. 
 

NSO Risk Advisor is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO Risk Advisor, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. The professional liability insurance policy is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Coverages, rates and limits may differ or may not be available in all States. All products and services are subject to change without notice. This material is for illustrative purposes only and is not a contract. It is intended to provide a general overview of the products and services offered. Only the policy can provide the actual terms, coverages, amounts, conditions and exclusions. CNA is a service mark and trade name registered with the U.S.Patent and Trademark Office. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc.; in CA (License #0795465), MN & OK, AIS Affinity Insurance Agency, Inc.; and in NY, AIS Affinity Insurance Agency. NSO Risk Advisor is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Suite 250, Fort Washington, PA 19034. Phone: (215) 773-4600.
 

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