We recently had an event where a full 50-mg tenecteplase vial was administered to a stroke patient. The root cause was that the nurse followed the dosing chart on the box, which is intended for the STEMI indication only.

Although tenecteplase is FDA approved for STEMI only, many hospitals are using it for stroke, which is endorsed by AHA/ASA guidelines.

A review of MSOS discussion threads shows that our hospital is not the first to experience this error. Many organizations are concerned about this mistake and are repackaging tenecteplase or affixing stickers to cover over the STEMI dosing chart. This has financial ramifications, though, as expired tenecteplase cannot be returned for a refund if the box is tampered with.

While we wait for tenecteplase to gain FDA approval for stroke, we cannot expect the manufacturer to add a stroke dosing chart, but we can ask them to remove the misleading STEMI dosing chart.

Receiving thrombolytic therapy is a decision patients weigh very carefully, as its potential risks are catastrophic. How can we allow this risk to be multiplied by accidental overdoses?

I would like to petition Genentech to remove the dosing chart from the tenecteplase box to prevent further errors, but I cannot do this alone. With the collective voice of our 4000+ members, this request will gain significance and impact.

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