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Reporting a Medication Error

Chlorhexidine oral rinse needs improved packaging

April 2, 2022

An oral surgeon sent a prescription for chlorhexidine gluconate 0.12% oral rinse for a woman to use after a dental procedure. The directions said to swish 15 mL around in her mouth for 30 seconds, then to spit it out. The pharmacy dispensed a 473 mL bottle of chlorhexidine manufactured by Xttrium Laboratories. This product has an opaque white, ridged plastic, squeeze-off child safety cap that was also to be used as a dosing cup to measure the 15 mL (Figure 1). However, the bottle may be difficult to open (the cap must be squeezed) and the instructions for opening the bottle are hard to find on the label. The cap has tiny, raised letters/numbers which are difficult to see (Figure 2), even with the cap tilted and under direct light. So, measuring the correct amount, 15 mL, may be difficult. Even more concerning is that some people who do not see the markings on the cap might assume the dose would be a capful (as it is for many over-the-counter mouthwashes and rinses).

Figure 1. A bottle of Chlorhexidine gluconate 0.12% oral rinse (Xttrium Laboratories) has a plastic safety cap that is also used to measure 15 mL doses.
Figure 2. The tiny, raised numbers/letters and15 mL dose line are difficult to see on the safety cap.

<span style="color: blue;">Here’s what you can do: </span>If you or a family member are prescribed chlorhexidine oral rinse, ask to speak with your pharmacist. Ask the pharmacist to show you how to open the bottle and measure a dose. If the cap is used to measure the dose, make sure you can see the markings. Otherwise, ask your pharmacist to provide you with an easy-to-read and appropriately sized metric-only dosing cup or oral syringe so you can safely measure the correct dose. Practice using the cup or syringe in front of the pharmacist to make sure you measure the right amount of medicine.

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