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6 Ways to Prevent Deadly Methotrexate Errors

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Overview: Methotrexate, a high-alert medication, has been associated with an alarming number of wrong-frequency errors, the Institute for Safe Medication Practices (ISMP) warns. Overdoses have resulted in vomiting, serious skin lesions, liver failure, renal failure and death.

What you can do: ISMP suggests several preventive measures to avoid errors around medication reconciliation, transitions of care, misunderstood instructions and look-alike, sound-alike issues.

More needs to be done to prevent wrong-frequency errors involving oral methotrexate, according to a new alert from ISMP.

Originally approved to treat cancer, methotrexate is a folic acid antagonist that is also used for non-oncologic indications, such as psoriasis, rheumatoid arthritis, ectopic pregnancy and multiple sclerosis. Typically, patients receive a low dose once or twice weekly. But because weekly doses of any medication are unusual, accidental daily dosing of oral methotrexate occurs frequently.

The wrong-frequency errors originate at all stages of the medication use process, from prescribing to self-administration, and have resulted in vomiting, serious skin lesions, liver failure, renal failure and death.

6 ways to prevent methotrexate dosing errors

Most of the errors associated with methotrexate can be prevented by fully implementing the following, according to ISMP:

  1. Default to a weekly dosing schedule in prescriber and pharmacy order entry systems.
  2. Require verification and entry of an appropriate oncologic indication in order entry systems for daily orders.
  3. Educate patients and provide them with verbal and written instructions that specify the weekly dosing schedule and which emphasize the danger of taking daily or extra doses.
  4. Validate patients’ understanding by asking them to repeat back the instructions for taking oral methotrexate.
  5. Verify the dose and frequency of all medication lists and discharge instructions.
  6. Limit the prescription quantity to a 30-day supply (e.g., dispense just eight 2.5 mg tablets for a 5 mg weekly dose would reduce the risk of a serious overdose).

For more information:

Read the ISMP’s “Call to Action: Longstanding Strategies to Prevent Accidental Daily Methotrexate Dosing Must Be Implemented.