Preventing Ozempic®-Related Medication Events

Insights from the AIMS Program

Data from the Assurance and Improvement in Medication Safety (AIMS) Program show an upward trend in the number of medication incident and good catch (near miss) reports involving Ozempic®.

There has been an increase of more than 250% in Ozempic®-related events reported through AIMS from 2019 to 2023.

From January 2023 to the end of June 2024, there were 222 Ozempic®-related events reported; of these, 77% were medication incidents, meaning they reached the patient.

28% of the events were reported as “patient incorrect” and 21% as “strength/concentration incorrect”
30% of the events occurred during the order-entry stage and 26% during the dispensing stage

The most common contributing factors reported were environmental distractions, drug-related issues, staff distribution, operational process issues and lack of staff education.

RECOMMENDATIONS TO MINIMIZE ERRORS

Ensure accurate order entry and dose titrations: For prescriptions with a complex titration regimen, consider inputting each titration step as a separate prescription and numbering the steps for clarity (e.g., Step 1, Step 2). This can help minimize dosing errors, such as patients repeating their starting dose based on refill labels.
Complete a thorough patient assessment and provide counselling: Verify the indication, ensure the dose and duration are appropriate and educate patients at each new step in the titration to ensure they understand the steps involved and their overall treatment plan.
Be aware of lookalike packages: Ozempic® is available in pens that provide different doses: the 2 mg pen delivers 0.25 mg and 0.5 mg doses, the 4 mg pen delivers 1 mg doses, and the 8 mg pen (approved but not currently marketed in Canada) delivers 2 mg doses. Educate all pharmacy staff on the different strengths, and make use of pop-up alerts and barcode scanning, if possible, to ensure the correct pen is dispensed.
Implement double-checks: Integrate multiple checks throughout the workflow to validate order entry and confirm dose calculations, product selection and labelling. At each check, confirm the dosage and ensure the correct number of pens are dispensed.
Enhance refrigerator organization: Organize Ozempic® prescriptions alphabetically by patient surname and maintain clear visibility of labels. Consider bundling pens/boxes for the same patient rather than storing them loosely. Always cross-verify patient names on each pen/box upon pickup.
Maintain adequate staffing: The Designated Manager (DM) in a community pharmacy is responsible for ensuring staffing and workflow support safe and effective delivery of patient care. When determining the number of pharmacy staff for each shift, consider both regular duties and any expanded scope activities offered.