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A pharmacist working in a pharmacy-run Injection Preparation Service received an order for "MTX 30 mg I.M. now." For some reason, even though he knew better, he thought of Mustargen as being the same as methotrexate. The abbreviation MTX signifies methotrexate. He reconstituted three 10 mg vials with one milliliter of sterile water for each vial and prepared a syringe containing 30 mg of Mustargen in 3 ml, thinking that this was actually methotrexate. The drug was to be administered to a pso..: riasis patient on a dermatology patient care area where methotrexate injection was commonly used. The pharmacist handed the syringe to a nurse and mentioned to her that for some reason he just didn't think everything seemed right. He was leery about administering the drug intramuscularly. The nurse assured him that methotrexate was given intramuscularly frequently and that everything was all right. But when the nurse looked at the pharmacy-prepared and -labeled syringe, she was surprised to see a different color and volume than she was used to seeing. However, since the syringe was properly labeled and was prepared by a pharmacist, she assumed that everything was correct and administered the drug in the patient's buttock.
Approximately two hours later, the patient began complaining of buttock pain. The nurse then became suspicious and called the pharmacist and it was then realized that Mustargen was administered-not methotrexate.
Immediate attempts were made to find information about" how the effects of this necrotizing agent could be reversed. A onesixth molar solution of sodium thiosulfate (prepared as described in the Mustargen package insert) was infiltrated in 5 ml doses in five spaces around the area of injection. No other therapy was discovered. Even the manufacturer of Mustargen was unable to be of help.
Contrary to what was expected, the patient miraculously suffered no toxicity from the dose or from the local effects as long as one month later.
Several things need to be examined about this incident in order to prevent similar errors in the future.
First of all, the abbreviation MTX should not have been used. This is initially what made the pharmacist think of Mustargen. Medications must always be prescribed by their official name.
Secondly, if the pharmacist was thinking that something didn't seem right, he should have had a colleague check the work he was doing. An examination of the vials used (Mustargen) by another pharmacist would have prevented the error.
Finally, the nurse who received the syringed and labeled medication from the pharmacist put blind faith in the pharmacist's work. The nurse recognized that a different color and volume of liquid than she was used to seeing with methotrexate injection was present in the syringe. Yet she failed to question the pharmacist because she trusted his work. One of the advantages of unitdose systems with prepared syringed injections is that a doublecheck exists before the patient receives the medication (pharmacist and nurse). This would not be true if the nurse prepared the injection. Errors in volume for the particular drug or route of administration are more easily discovered with a double-check, and color differences may be questioned to learn if the wrong drug was prepared. But you must question any recognized discrepancies.