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A young man who had a ruptured lumbar disk was admitted for a laminectomy. Because he had leg cramps, his doctor ordered quinine sulfate, 325 mg, to be given orally three times a day.
Five days after his admission, the patient underwent the laminee to my. During surgery, he developed premature ventricular contractions. The patient, who had no history of cardiac problems, was taken to the intensive care unit (ICU) after surgery so his heart function could be closely monitored.
In trying to understand what had happened to the patient, the ICU nurse reviewed his medication administration record. She discovered that instead of transcribing quinine sulfate, the ward clerk had mistakenly written quinidine sulfate. The patient had received this cardiac depressant for 5 days.
If the ward clerk's work had been checked more carefully, this error probably wouldn't have happened. But even if the transcription error had slipped through, the nurses administering the drug should have asked themselves why a patient with no history of cardiac problems was receiving a cardiac depressant.
To prevent this type of error, alert co-workers to drugs with similar names. Double-check transcriptions of drug orders. Ask yourself why a patient is being given a particular drug. If the order doesn't make sense, clarify it with the doctor.
Finally, except for malaria, quinine has not been proven effective for other indications. Perhaps it doesn't ever need to be in your hospital. Then it can't be mixed up.