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A new staff nurse was passing out medications for the first time. She was doing well until she came across an order for "5-ASA at bedtime." She opened a box of unit -dose aspirin and prepared to give the patient five aspirin tablets. The supervisor caught her in time and explained that the order was for mesalamine (Rowasa) enema, a relatively new drug used to treat ulcerative colitis.
For years, doctors treated ulcerative colitis with an oral drug, sulfasalazine (Azulfidine). The active metabolite of sulfasalazine is 5-aminosalicylic acid, or, as it's sometimes called, 5-ASA. Mesalamine is a formulation composed purely of that metabolite, and sometimes a doctor will improperly use the abbreviation 5-ASA when ordering the new drug.
The doctor wrote the order for 5-ASA, then compounded his error by giving an incomplete order. If he'd specified that mesalamine is an enema, or included directions, the new nurse might have questioned the order.
One way to reduce the chance that this mistake will occur is to discourage doctors from using 5-ASA as an abbreviation. Another is simply to be aware that the problem exists.