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Publication Type: OBS Messages
Single or Multiple Incident: Multiple
Date: 9/7/2017 12:00:00 AM
Country: Denmark
This alert discusses the medication incidents that can occur when methotrexate is given daily instead of the intended weekly regimen. Three cases are referenced, one of which was fatal. Methotrexate used in low doses for the treatment of rheumatoid arthritis and psoriasis is one of the seven groups of drugs that the Danish Agency for Patient Safety describes as risk situation drugs. There is an increased risk of prescribing and dispensing errors due to the atypical dosage: Once weekly instead of once daily. Recommendations to ensure the correct frequency of administration of methotrexate are provided.

Additional Details

Medication/Gas/Fluid:
methotrexate oral
Medication/IV List:
methotrexate, oral, non-oncologic use

Rules / Policies / Procedures
  1. Methotrexate should be taken at once on a fixed day of the week. A visible and unambiguous dosage text can be an aid in dispensing. Make sure you do not overlook or misunderstand the weekly dose note in the medication schedule.
  2. Handling methotrexate requires special safety measures, such as double-checking.
Training
  1. Knowledge about methotrexate among healthcare professionals handling the drug is important for patient safety.

Be aware of methotrexate overdose due to daily treatment instead of weekly