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After receiving a liver transplant, a 31-year-old woman with impaired renal function developed pneumonia. Her doctor ordered I.V. vancomycin (Vancocin) to treat one of the causative organisms, a resistant staphylococcus. To protect the patient's renal function, he ordered the drug given every 96 hours.
Weeks later, while still receiving I.V. vancomycin, the patient developed pseudomembranous enterocolitis. The infectious disease specialist recommended oral vancomycin. The intern, thinking the oral drug would replace the I.V. drug, ordered the I.V. vancomycin discontinued and oral vancomycin given instead.
Unfortunately, the intern didn't know that each of these two forms of vancomycin has a specific indication. Oral vancomycin effectively treats pseudomembranous enterocolitis, but is not effective for systemic infections because it's not absorbed when taken by mouth. And I.V. vancomycin, which is effective against systemic infections, won't treat pseudomembranous enterocolitis. The patient needed both forms of the drug.
The error went unnoticed for some time because the I.V. vancomycin had been given so infrequently. When the patient's regular doctor discovered what had happened, he ordered an immediate I.V. bolus of vancomycin, followed by resumption of the original I.V. regimen. The patient pulled through and was eventually discharged.
A series of assumptions led to this error. One, the infectious disease specialist assumed that the intern knew to continue the I.V. drug. Two, the intern (and the patient's nurses) assumed that the oral drug could replace the I.V. drug. And three, the pharmacist who reviewed the intern's order assumed that the patient no longer needed the I.V. drug.
Don't let assumptions endanger your patients. Know what you're giving and why.