ISMP MEDICATION SAFETY ALERT - CONFUSION BETWEEN TWO FORMS OF "EDTA" We learned last month about a 5-year-old boy who died from a drug mix-up. During chelation therapy for autism, the child was given edentate disodium instead of edetate calcium disodium (CALCIUM DISODIUM VERSENATE, also referred to generically as calcium EDTA). Edetate calcium disodium is used to treat acute and chronic lead poisoning and lead encephalopathy, while edetate disodium is used in the emergency treatment of severe hypercalcemia. The potential for confusing these medications is high as both are commonly referred to as "EDTA." Although the latest death of a 5-year-old boy took place in a physician's office, this tragedy indicates that warnings about potential confusion between these products are worth repeating, especially since the drugs are occasionally used in acute care settings. Edetate calcium disodium is used to treat acute and chronic lead poisoning and lead encephalopathy, while edetate disodium is used in the emergency treatment of severe hypercalcemia. Unfortunately, both are commonly referred to as "EDTA." In order to distinguish between the products and avoid improper use of nomenclature, nurses and pharmacists must have an understanding about why the drug is being prescribed. Reminders about potential confusion should appear on the computer screen whenever orders are processed for either drug. We would also suggest that packages of each drug have an auxiliary label affixed to remind staff about the need to match the drug with the patient's diagnosis.
ISMP Medication Safety Alert!(R)
February 9, 2006 Volume 11, Issue 3
They took her to the hospital and someone administered the wrong drug and she died. As I remember, the family did not sue. They did not have the strength in them to even consider it. Their grief was too great. As I recall it was their only child and she was born when the mother was in her 40s.
I guess it shows terrible accidents can, and do happen.