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A 91-year-old woman was to undergo bowel resection. A surgeon wrote the following order as part of preoperative bowel preparation:
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No route of adminstration was specified. The first dose was requested verbally from the pharmacy as "Kantrex 500 mg 1.M. " Subsequent doses were scheduled in the nursing medication administration records to be given intramuscularly. When the pharmacist received the written order and saw the dosage ordered, it was obvious to him that the drug was meant to be given orally.
This error could have had serious consequences. The nephrotoxicity and ototoxicity of systemic kanamycin is well known. If the drug were given systemically in the dosage ordered, these side effects would be likely to occur. Because the oral dosage form (capsule) is not appreciably absorbed, this form is used in doses much higher than those used systemically. Its local effect within the bowel lumen reduces bowel flora before operation.
One of the factors that led to this error was that no route of administration was specified by the doctor. Because not everyone is familiar with the oral dosage form, and because the use of kanamycin by parenteral route or as an irrigation is better known, the lack of specification of route of administration led to the belief that the intramuscular (I.M.) route was to be used.
Personnel responsible for scheduling and administering medications in this hospital showed a lack of information about the dosage range of kanamycin and about the serious side effects of the drug that are more likely with high doses. If this had been known, the error would not have occurred. Hospitals must have policies that require pharmacists to see a written order before any nonemergency drug is dispensed.