Recombinant human erythropoietin dosing errors due to concentrated EPO

Area of Science:

• Pharmacology
• Nephrology
• Patient Safety

Background:

• Recombinant human erythropoietin (rHuEPO) is a standard treatment for anemia, particularly in dialysis patients.
• A dialysis provider implemented a policy using 20,000 U/ml multi-dose vials for rHuEPO administration.
• Accurate dosing is critical for therapeutic efficacy and patient safety.

Purpose of the Study:

• To evaluate the accuracy and precision of administering small doses of rHuEPO from 20,000 U/ml multi-dose vials.
• To identify potential medication errors associated with this dosing strategy.

Main Methods:

• Ten registered nurses (RNs) administered simulated low doses (1,200 U, 2,400 U, 3,600 U) of rHuEPO using water-filled vials.
• Doses were drawn in duplicate using microliter pipettes, and volumes were measured.
• The equivalent rHuEPO amount was calculated based on the assumed concentration of 20 U/microliter.

Main Results:

• Significant dosing errors were observed, with some exceeding 100% at the 1,200 U dose.
• Variability in dosing was noted, with inter-RN error (29.8%) being greater than intra-RN error (9.6%) at the 1,200 U dose.
• Errors included both under- and overdosing of rHuEPO.

Conclusions:

• The use of concentrated rHuEPO vials for small-dose administration results in substantial inaccuracies.
• These dosing errors can lead to incorrect medication administration and discrepancies in billing.
• Healthcare policies involving medication administration require thorough evaluation for their impact on patient safety and outcomes.