Lack of Standardized Documentation Contributes to a Mix-up between Methadone and Buprenorphine-Naloxone
This bulletin follows a case reported to ISMP of a patient who was administered methadone despite being prescribed buprenorphine-naloxone. The mix-up happened because of incomplete documentation in the medication administration record, and a lack of an independent double check.
- Opioid use disorder
- Opioid agonists
- Dose administration documentation
- Dispensing protocols
- Supporting Safe Medication Use during Periods of Fasting