Quality & Patient Safety

Tamiflu ® shortage sparks dosing confusion at some facilities

Patient Safety Monitor Alert, November 4, 2009

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The Pennsylvania Patient Safety Authority has issued an advisory regarding the use of Tamiflu in conjunction with proper dosing. Because of a shortage of commercially available Tamiflu oral suspension, some pharmacies have begun compounding Tamiflu according to Food and Drug Administration-approved directions. However, the commercially available Tamiflu is created in a 12 mg/mL base concentration, whereas the newly compounded Tamiflu is created in a 15 mg/mL base concentration.

So far, two patients have been reported to receive overdoses but have not been harmed. The Institute for Safe Medication Practices, which produced the advisory in conjunction with the ECRI Institute, recommends that prescribers communicate suspension doses in mg rather than by volume to avoid any confusion.

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