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An oncologist instructed a medical student to write an order for 8 mg daily of chlorambucil (Leukeran) on the chart of a patient with Hodgkin's disease. The student inadvertently wrote the order on the chart of the patient's roommate (who had been admitted for an appendectomy). The order was processed by the nursing and pharmacy personnel and the drug was given to the wrong patient for 2 weeks. The mistake was discovered only when a routine blood count showed the patient receiving the drug had a severe bone marrow depression.
Probably, your first reaction is to blame the medication error directly on the student. Actually, the responsibility must also be shouldered by others.
First, the oncologist disobeyed the hospital's rule that all orders written by students must be countersigned by a doctor. Second, the pharmacists and nurses should not have carried out an order that wasn't properly countersigned. Third, and most important, the nurses and pharmacists should have known the diagnosis of the patient for whom the order was written.
Giving drugs, particularly cancer drugs, is a tremendous responsibility. Those administering the drugs must know the patient's diagnosis as well as his allergies-if any-and make sure these are noted on the patient profile and Kardex.
All this seems so basic that many of us assume it's automatically done. Yet, far too often, when the people administering the drugs are asked if they've checked out the patient's diagnosis or allergies, they answer, "1 didn't have the time," or "It just slipped my mind." Obviously, these answers wouldn't hold up in court, if litigation resulted from a medication error. And, bringing it closer to home, if your loved one were injured by a medication error, how would you react to such an explanation?