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A patient recovering from a total hip replacement developed an infection around the prosthesis. A 1-month course of antibiotics eventually brought the infection under control. Unfortunately, the antibiotics caused pseudomembranous colitis, a serious adverse reaction. The doctor ordered oral vancomycin (Vancocin), commonly used to treat this condition.
Although oral forms of vancomycin are available, the pharmacist had only injectable vancomycin in stock. Following the accepted procedure, he added water to the contents of an injectable vial so the drug could be given orally. But he neglected to specify the oral route on the vial's label.
When the medication nurse received the vial, she failed to check the patient's medication administration record (MAR), which clearly stated that the drug was to be given orally. She drew up the vial's contents and administered the medication I.V., through a volumecontrol set.
The patient suffered no harm from this error, but neither did he receive any benefit from the drug-I.V. vancomycin is relatively ineffective for pseudomembranous colitis. Both the pharmacist and nurse contributed to this error. The pharmacist dispensed an injectable drug without noting that it was to be given orally. The nurse gave the drug without first checking the MAR.
Don't make the same mistake: Always verify a drug's administration route. And remember that vancomycin should be given orally for pseudomembranous colitis.