Multidose Nitroglycerin Bottles Associated With 25-Fold Overdose Errors

The Patient Safety Authority has received multiple reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing erroneous dispensing and administration of whole bottle contents (up to 25 tablets) of sublingual nitroglycerin instead of a single tablet.As a result of these events, patients have required resuscitative measures and/or transfer to a higher level of care.Sublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease. 1 The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air. 2 The loss of potency from environmental exposure 2 often prevents repackaging of the tablets from a multidose bottle into single doses.Therefore, without single doses prepackaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur.