Methotrexate dispensing errors

THE Therapeutic Goods Administration’s newly constituted Advisory Committee on Medicines has suggested a range of measures to reduce the risk of dosing errors around low-dose methotrexate.

A statement from the Committee’s first meeting in Feb, made public yesterday, details advice provided in relation to the weekly methotrexate tablets which have been subject to inadvertent dosing errors, including “accidental daily administration” which has led to serious harm to patients.

Dispensing errors by pharmacists, including incorrect and unclear instructions, incorrect product selection and incorrect packing of methotrexate into dose administration aids were cited as key factors, along with prescribing errors and patient/carer error.

The committee said it was concerned that “avoidable methotrexate dosing errors continue to cause significant harm to a small number of patients, despite this being an identified risk for several decades”.

Suggestions to address the issue include revised Product Information to highlight critical safety measures, and a separate ‘black box’ warning.

Additional risk management measures that could be considered include a patient dosing card, reduced pack sizes to suit weekly administration, collaboration with education providers, and redesigned product packaging including changing the product name to include ‘WEEKLY’.