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Health: Drugs

Volume 708: debated on Wednesday 4 March 2009

Question

Asked by

To ask Her Majesty's Government what is the total number of prescribing and dispensing errors involving immunosuppressant therapies Prograf and Advagraf by (a) prescribing clinicians, and (b) dispensing healthcare professionals. [HL1662]

The National Patient Safety Agency has advised that 19 patient safety incidents relating to prescribing and dispensing of immunosuppressant therapies Prograf and Advagraf were submitted to its reporting and learning system between 1 January 2005 and 30 November 2008.

These include nine prescribing incidents. Five of these related to omitted or delayed doses of Prograf or Advagraf in hospital settings, one to a poorly hand- written prescription, two where the wrong formulation of tacrolimus (the active ingredient in these therapies) had been prescribed and one to a possible interaction between an oral antibiotic and Prograf.

The remaining 10 were dispensing incidents. In four of these, the wrong formulation of tacrolimus had been dispensed. Two incidents related to omitted or delayed doses of Prograf or Advagraf in hospital settings, two where there was an unclear or wrong dose, one incident involving expired stock and one incident where the wrong quantity of capsules had been dispensed.

All 19 incidents resulted in low or no harm.