Wrong-Route Errors Involving Haloperidol: Beware of Its Unintended Intravenous Administration

Haloperidol is a butyrophenone antipsychotic that is approved for the treatment of schizophrenia.¹ Only the intramuscular route is approved for parenteral use by the U.S. Food and Drug Administration (FDA); however, intravenous (IV) haloperidol lactate has been used over the years for several off-label indications.^2–4 The long-acting depot formulation, haloperidol decanoate, should never be administered intravenously.⁵

The IV administration of haloperidol carries a label warning relating to QTc prolongation and Torsades de Pointes, for which electrocardiogram monitoring is recommended.^1,5 A review of Pennsylvania Patient Safety Reporting System (PA-PSRS)^[1] event reports found adverse drug reactions involving IV haloperidol include ventricular tachycardia, apnea requiring intubation, neuroleptic malignant syndrome, and seizure.

Over 200 events describing wrong-route errors involving haloperidol have been reported to PA-PSRS. Of these, almost half detail cases in which parenteral haloperidol, which was originally intended for intramuscular injection, was administered intravenously. Most of these events involve the haloperidol lactate formulation; however, accidental IV administration with the decanoate formulation has also been reported.

To prevent wrong-route errors with haloperidol lactate, we advise that facilities examine and consider implementing the action items below.

• Restrict verbal orders to urgent situations where computerized provider order entry is not possible or practical. Reevaluate and/or create guidelines for the appropriate use of verbal orders, specifying the required information that should be included and recommending safe practices such as the readback method to confirm the order.

• Require pharmacist verification of the order and subsequent profiling of medication in the automated dispensing cabinet (ADC).

• Follow proper protocol in labeling and scanning the medication prior to administration.

• Create an alert in the ADC and/or barcode medication administration to remind the user of the intended route of administration.

• Reduce distractions during dispensing, preparation, and administration of the medication.

• Supervise students and trainees throughout all stages of the medication-use process.

Disclosure

The author declares that they have no relevant or material financial interests.

This article was previously distributed in an August 7, 2024, newsletter of the Patient Safety Authority, available at https://conta.cc/3ytbCpw.

About the Author

Myungsun (Sunny) Ro (mro@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority (PSA). Her responsibilities include analyzing and synthesizing data from various sources to identify opportunities to improve patient safety, as well as writing scientific articles for publication in the PSA’s peer-reviewed journal, Patient Safety.