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A 64-year-old woman was hospitalized for treatment of rheumatoid arthritis. Her doctor wrote the following order for the antiinflammatory drug Feldene (piroxicam):
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Both the patient's nurse and the hospital pharmacist interpreted the "p.c." to mean "after each meal," and that's how the drug was scheduled.
The patient was given Feldene three times a day for more than a week. Then she began vomiting blood. Studies revealed severe anemia and a peptic ulcer. The doctor ordered several units of blood administered, then set out to find the cause of the bleedmg.
His search didn't take long. As soon as he reviewed the patient's medication administration record, he saw that she was being given Feldene three times a day, not once a day as he had intended. He was well aware that this drug can cause bleeding, even when given no more than once daily as recommended. The doctor discontinued the Feldene and prescribed drug therapy for the patient's ulcer.
The doctor, nurse, and pharmacist all contributed to this error. The abbreviation "p.c." commonly means "after a meal." The doctor wrote an incomplete order by not specifying after which meal or noting that the drug was to be given only once a day. The nurse and pharmacist transcribed, filled, and carried out the order mechanically, without considering that it was incomplete. Ironically, both said later that they knew Feldene shouldn't be given more than once daily. But when they reviewed the order, they were so busy they didn't give it a second thought.
Don't let a hectic pace cause an error. When you're especially busy, review drug orders even more diligently. Think each order through, and clarify those that are incomplete.