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While a medication nurse was preparing for her morning rounds, she was interrupted by a doctor who was also making rounds. The doctor asked the nurse if she knew what was wrong with Mr. Stanislavsky, a 68-year-old man who was being treated for pneumonia. The doctor said the patient looked as if he'd suffered a stroke.
The nurse accompanied the doctor to Mr. Stanislavsky's room and found the patient unconscious. She took his vital signs: He had a slightly elevated pulse and low blood pressure.
The doctor immediately started an infusion of D5 W, first drawing a blood sample for a stat blood glucose test.
When another nurse came in to monitor the patient, the medication nurse left to review the patient's medication administration record and look for clues to his condition. She found that a new drug, an antidepressant, had been ordered the previous evening. The medication sheet listed the new medication as Sinequan (doxepin), 250 mg, every 6 hours. The nurse immediately recognized that this dosage was much too high. She also wondered why Sinequan had been ordered-she had not been told of any diagnosis of depression.
The nurse then checked the patient's chart and discovered what had happened. On the doctor's order form, she saw an order for the antibiotic Sumycin (tetracycline), 250 mg, every 6 hours. Apparently, the unit secretary had misread the doctor's handwriting, interpreting the drug name as Sinequan rather than Sumycin.
The night nurse, who had checked the orders transcribed by the unit secretary, didn't catch the erroneous transcription. And since the doctor had written the order in the evening and the hospital didn't have an evening pharmacist, it had been filled by a community pharmacist. Therefore, the order hadn't been reviewed by a hospital pharmacist, who would have been likely to notice the high dosage.
The patient recovered from the overdose, but he remained unconscious for a full day. Also, several laboratory tests were needed to monitor the patient's condition, adding to the expense of his hospitalization. Besides causing these effects, this medication error brought the patient's family additional stress.
This kind of error can be prevented by following a few basic rules:
Finally, hospital administration can help prevent similar errors by establishing a 24-hour pharmacy service or enforcing a policy that the hospital pharmacist be contacted before any medication is obtained from a source other than the hospital pharmacy.