How Are You Preventing Acetaminophen Overdoses? ISMP Medication Safety Alert

An ISMP Medication Safety Alert posted on August 8, 2003, reported that while community pharmacists are increasingly aware of the dangers patients face when taking multiple products containing acetaminophen, hospital pharmacists must step up their vigilance. Multiple PRN pain orders for acetaminophen alone and in combination with other pain relievers are common in hospitals. Most hospitals maintain floor stock supplies of acetaminophen, thus making it possible only after the fact for pharmacists to determine total daily dosage. This Institute for Safe Medication Practices (ISMP) alert describes how one hospital's retrospective study found that an average of one patient per day exceeded the 4-gram maximum of acetaminophen. The ingredients most commonly implicated were hydrocodone and 500 mg of acetaminophen. A printed cautionary note on all acetaminophen products placed in the medication administration report (stating "Do not exceed 4 grams within a 24-hour period") was insufficient to avoid the overdosing. Subsequently, the hospital's Pharmacy and Therapeutics Committee is looking into solutions. Suggestions for preventing hospital-based overdosing of acetaminophen should be sent to ismpinfo@ismp.org. For further information go to: http://www.ismp.org/msaarticles/overdoseprint.htm Return to Top