Error Number 178. Mistaking "folinic acid" for "folic acid"

.A cancer patient was scheduled to receive a course of methotrexate therapy, followed 6 hours later by a dose of leucovorin calcium (folinic acid). In this procedure, known as rescue therapy, leucovorin calcium counteracts some of methotrexate's adverse systemic effects~ The doctor wrote the order as folinic acid.

When the medication nurse took the leucovorin calcium to the patient 6 hours after the methotrexate course was completed, he fell asleep. The nurse confused folinic acid with folic acid, a vitamin. Thinking she wouldn't wake him for "just a vitamin," she withheld the dose. It was administered the next morning. Fortunately, the patient suffered no ill effects.

Certainly, the medication nurse who was unfamiliar with the official name for folinic acid erred in her judgment to withhold the dose without consulting the doctor. But other safeguards could have prevented this error. For another thing, the pharmacist could have attached a label explaining leucovorin calcium's action in methotrexate therapy. For another, the doctor could have written the official generic name, leucovorin calcium, on the order to avoid confusion.

But the best way to prevent this error would have been to make sure all staff members who handle drugs understand them thoroughly. If the nurse had known why the folinic acid was to be administered, she wouldn't have assumed it was "just a vitamin.