Multifactorial Causes of Tacrolimus Errors: Confusion With Strength/Formulation, Look-Alike Names, Preparation Errors, and More Ensuring Safety of Recipes for Drug Compounding Please, no more teaspoon dosing.

A recent string of errors associated with tacrolimus, an immunosuppressant used primarily to prevent rejection in transplant recipients, prompted ISMP to review the literature and analyze related events reported to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and the ISMP National Medication Errors Reporting Program (MERP). We found that tacrolimus has been involved in many reported errors during the past decade that have been caused by a wide variety of factors, the most common of which are described below.