Christ Hospital employees Grace Esposito, RN, left, an OR nurse, and Patricia Swed O’Connor, RPh, director of pharmacy, show two different drugs that no longer look-alike. One top is now green, and the other is white to reduce the possibility of error.
Photo courtesy of Christ Hospital
At Christ Hospital in Jersey City, N.J., putting patients first and ensuring their safety was all in a day’s work for an operating room nurse and a hospital pharmacist. The two became acquainted after Grace Esposito, RN, noticed that two vials of drugs looked similar and feared it would lead to a medication error.
“I was stunned to see two different vials of injectable drugs that looked the same: same size, same shape, same green top,” Esposito said in a news release. “The lettering was different but they looked so similar it was frightening. I notified my supervisor and called the hospital’s pharmacy immediately.”
Esposito was concerned because both generic drugs — Oxytocin and Methylergonovine — are routinely prescribed for obstetrical patients. Although the drugs looked alike, they are not interchangeable. Mistaking one for the other could result in a serious adverse event.
“The potential for error definitely existed. We had to think outside of the box and find an alternate generic Oxytocin with completely different packaging,” Patricia Swed O’Connor, RPh, director of the pharmacy at Christ Hospital, said in a news release. “To ensure patient safety, we found another manufacturer, and now the two drugs look nothing alike. We are proud of the interdisciplinary collaboration which promotes a culture of patient safety here at Christ Hospital.”
O’Connor contacted the Greater New York Hospital Association and the Institute for Safe Medication Practices to tell them about the potential for error and recommended the manufacturer change the packaging.
“Speaking up for patient safety is the essence of putting patients first,” Maureen Fitzsimmons, RN, CNAA, BC, vice president of patient care services, said in a news release. “Ms. Esposito and Ms. O’Connor truly showed their commitment by tracing a relatively small but critical issue all the way back to the manufacturer to reduce the risk of harm for patients.”
“I was stunned to see two different vials of injectable drugs that looked the same: same size, same shape, same green top,” Esposito said in a news release. “The lettering was different but they looked so similar it was frightening. I notified my supervisor and called the hospital’s pharmacy immediately.”
Esposito was concerned because both generic drugs — Oxytocin and Methylergonovine — are routinely prescribed for obstetrical patients. Although the drugs looked alike, they are not interchangeable. Mistaking one for the other could result in a serious adverse event.
“The potential for error definitely existed. We had to think outside of the box and find an alternate generic Oxytocin with completely different packaging,” Patricia Swed O’Connor, RPh, director of the pharmacy at Christ Hospital, said in a news release. “To ensure patient safety, we found another manufacturer, and now the two drugs look nothing alike. We are proud of the interdisciplinary collaboration which promotes a culture of patient safety here at Christ Hospital.”
O’Connor contacted the Greater New York Hospital Association and the Institute for Safe Medication Practices to tell them about the potential for error and recommended the manufacturer change the packaging.
“Speaking up for patient safety is the essence of putting patients first,” Maureen Fitzsimmons, RN, CNAA, BC, vice president of patient care services, said in a news release. “Ms. Esposito and Ms. O’Connor truly showed their commitment by tracing a relatively small but critical issue all the way back to the manufacturer to reduce the risk of harm for patients.”
