Clinical Safety Issue – Automatic Pre-Population of Incorrect Volume of Enoxaparin and Other Products Prescribed in the Form of Pre-Filled Syringes

Cegedim Healthcare Solutions has been made aware of an issue relating to an incorrect volume/presentation of Enoxaparin and some other products prescribed in the form of pre-filled syringes being automatically pre-populated in the ‘Drug:’ field of the Vision 3 therapy (prescribing) form when searched for using the drug field. The issue originally reported is that, within the therapy form, entering ‘enox 40’ in the drug control to search for the product ‘Enoxaparin sodium 40mg/0.4ml solution for injection pre-filled syringes’ (a 40mg dose) incorrectly brings up the 100ml/1ml prefilled syringe (100mg dose) in the ‘Drug:’ field:

In addition to Enoxaparin and its various brand names (e.g. Inhixa), this issue has been observed with some other products prescribed in the form of pre-filled syringes. This presents a clinical safety issue as it introduces a potential risk of overdose as a result of a prescribing error where a prescriber does not notice the incorrect product selection and amend to a lower volume of product for administration where required and the higher volume is prescribed, dispensed to and taken by the patient (e.g. the 100ml/1ml Enoxaparin item instead of the desired 40mg/0.4ml Enoxaparin product).

While Cegedim Healthcare Solutions investigate this further, as an interim mitigation against the associated clinical safety risk, we would ask that prescribers are vigilant and take extra care when prescribing Enoxaparin and other products prescribed in the form of pre-filled syringes to ensure that the correct, desired volume of product is prescribed.

 In Vision 3, either of the following methods is currently recommended when prescribing these products.

 1) Add another search word in the drug field of the Vision 3 therapy (prescribing) form to indicate the form of the product desired. This will return the expected drug item. For example, where the Enoxaparin product desired to be prescribed is ‘Enoxaparin sodium 40mg/0.4ml solution for injection pre-filled syringes’, entering ‘enox 40 inj’ in the drug field results in the expected drug volume being pre-populated in the ‘Drug:’ field.  

2) The ‘Select Drug’ feature in Vision 3 may be used to search for and select drugs and is not affected by this issue. To open the ‘Select Drug’ feature, double-click in the ‘Drug :’ field. Using the example above, entering ‘enox 40’ in the drug search dialogue finds the expected Enoxaparin item ‘Enoxaparin sodium 40mg/0.4ml solution for injection pre-filled syringes’.

Guidance on using the Select Drug feature is available at https://help.cegedim-healthcare.co.uk/Vision_Consultation_Manager_Help_Centre/Content/ConMgr/Therapy/Using_the_Select_Drug_Screen.htm?Highlight=search%20for%20drug

Behaviour of Vision Anywhere

A similar issue has been noted to also occur in Vision Anywhere. For example, where entering ‘Enox 40’ in the ‘Drug name’ field of the Prescribe form, a list of Enoxaparin products of different volumes is returned rather than just the expected item of ‘Enoxaparin sodium 40mg/0.4ml solution for injection pre-filled syringes’. Cegedim Healthcare Solutions are also continuing to further investigate this issue in the Vision Anywhere application.