Reported medication errors associated with methotrexate

Multiple toxic effects of low-dose methotrexate in a patient treated for psoriasis

“…Polypharmacy also played a role in 72% of the cases described by Moore et al 30 (mean number of drugs = 3.5). Our patient was taking 12 medications, which could have been another determining risk factor for a potential medication error.…”

“…[26][27][28] In 2002, the Institute for Safe Medication Practices released an advisory because reports had been made about methotrexate overdose with inadvertent administration of methotrexate daily instead of weekly. 29 Two years later, Moore et al 30 reported that 106 medication errors in which methotrexate was identified as the contributor were reported to the Food and Drug Administration between 1997 and 2001. Rheumatoid arthritis (42%) and psoriasis (12%) were the most common indications with 52% of the reported errors associated with a form of overdose (daily instead of weekly = 30%).…”

Electronic screening of medical records to detect inpatients at risk of drug-related problems

“…These medications are often involved in clinically relevant interactions or have a narrow therapeutic window [4][5][6][7]. • Patients with renal impairment (creatinine clearance Cockcroft-Gault \ 60 ml/min [8,9]).…”

Development of an algorithm to detect methotrexate wrong frequency error using computerized health care data

“…Methotrexate is FDA approved for use in managing rheumatoid arthritis (RA), certain neoplastic diseases, and recalcitrant psoriasis and is prescribed for daily or weekly administration based on the indication for use . Oral methotrexate, when used for RA, is associated with “wrong frequency error,” with daily instead of the intended weekly dosing schedule . Wrong frequency errors result from physician prescribing, pharmacist dispensing, and patient and caregiver administration.…”