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Repackage One Dose Per Bag

Kate Traynor

Taking a shortcut when dispensing medications not furnished in unit dose packaging can be risky for patients.

The July 26 ISMP Medication Safety Alert!, from the Institute for Safe Medication Practices (800-FAILSAF,, warned against placing several doses of a patient’s medication in a poorly labeled bag for delivery to the nursing unit's drug-storage area.

Because not all oral medications are marketed in unit dose packaging, a hospital pharmacy furnished nursing units with multiple doses of these drugs in resealable bags. In some cases, multiple doses representing a 24-hour supply of a patient’s medication were placed in a single, irregularly labeled, resealable bag and sent in the medication cart. At this hospital, the medication carts were exchanged daily at 3 p.m.

An investigation to uncover why medications scheduled for administration at 9 a.m. were missing from the medication carts revealed that some nurses may have assumed that a bag contained a single dose of medication. These nurses would have administered the entire contents of the bag—perhaps more than two doses—to the patient at one time.

To remedy the problem, the pharmacy staff began placing no more than one dose of medication in each resealable bag. Improvement was noted in one week. According to ISMP, the new procedure produced dramatic changes in the hospital’s ability to account for its medications.

This Medication Errors Alert was adapted with the permission of the Institute for Safe Medication Practices (ISMP) and is provided by the American Society of Health-System Pharmacists Center on Patient Safety and ISMP (1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006; 215-947-7797). Practitioners can report medication errors at and discuss errors in confidence at