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A doctor asked his resident to order AZT (azidothymidine),
200 mg, every 4 hours, for one of his patients. Azidothymidine is the old name for zidovudine (Retrovir), the drug used to treat signs and symptoms of acquired immunodeficiency syndrome (AIDS). The resident mistakenly ordered azathioprine (Imuran), an immunosuppressant normally given to transplant patients be¬fore and after surgery. The unit secretary entered the order into the medication administration record, then forwarded it to the pharmacy.
The pharmacist questioned the order when he realized that an AIDS patient shouldn't be receiving an immunosuppressant. The dosage was wrong, too-azathioprine is usually given once a day, not every 4 hours. The pharmacist called the nursing unit; the patient's nurse located the doctor, who clarified the order. The patient received the correct drug.
Using the current names for the AIDS drug-zidovudine or Retrovir-instead of the old abl;Jreviation AZT would prevent this kind of mix-up. In fact, hospitals should ban abbreviations for all drugs, except for those that are well-established and appear on an approved hospital list (like MOM for milk of magnesia).