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An inpatient prescription written for fluphenazine hydrochloride (Prolixin Elixir) was filled in the pharmacy in a 4 oz. pharmacy glass bottle. It was labeled as 0.5 mg/m!. Since the dose prescribed was 5 mg, the pharmacist who filled the prescription assumed that a floor employee would use a dose measurer to pour 10 ml of the 0.5 mg/ml liquid. However, someone, apparently thinking it would be more convenient to use a dose-graded dropper to measure the dose, placed a dropper from an empty bottle of Stelazine Concentrate into the Prolixin bottle. The dropper cap fit perfectly. The measurements on the Stelazine Concentrate (10 mg/ml) dropper are 10 mg, 8 mg, and 5 mg. Each of several doses of 5 mg was measured by using the 5 mg increment on the Stelazine dropper. The dose actually administered then was 0.25 mg of Prolixin, a good deal less than the 5 mg intended.
Several factors contributed to this medication error. First and obvious is that droppers meant for one particular medication are not interchangeable for use with another. They should not be used to cap a bottle of another drug, even on a temporary basis, such as if the original nondropper cap was lost or broken. The dropper itself in this case clearly stated "Stelazine." If this had been read, perhaps the error would not have occurred.
The labeling placed on the bottle in the pharmacy is also open to criticism. The label should have stated the volume of elixir necessary to administer the 5 mg dose. If prepackaged unit doses of liquids were utilized, this type of error would not have been possible.