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An oncologist wrote an order for folinic acid, 10 mg, P.O., for a cancer patient who was receiving chemotherapy with the antimetabolite methotrexate. The order was written at night after the pharmacist had gone home, so the nursing supervisor had to obtain the drug.
The supervisor searched the pharmacy shelves for folinic acid, but could find only folic acid. Assuming the two drugs were the same, she sent 10 I-mg tablets of folic acid to the unit with instructions to administer all 10 tablets.
Because the patient's nurse wasn't familiar with folinic acid, she looked for it in a drug reference but couldn't find it. Assuming the supervisor must have already confirmed that folic acid and folinic acid were the same, she administered the folic acid.
The next morning when the pharmacist reviewed orders and drugs signed out during the night, he discovered the error. The patient suffered no adverse effects from the folic acid, but of course he didn't receive the benefits of folinic acid.
Folinic acid's proper chemical name is leucovorin calcium, which is why the nurse couldn't find folinic acid in the reference she checked. Leucovorin is frequently given after methotrexate administration to counteract some of this drug's adverse effects. This use is called rescue therapy, or leucovorin rescue.
To prevent such errors, cancer•drugs should ideally be administered on oncology units staffed by personnel familiar with chemotherapy protocols. Practically, though, this may not be possible. But wherever cancer drugs are given, the staff must be taught how to give them ... and have access to the protocols.
Also, hospital administration can help prevent cancer drug errors by establishing a policy that all orders for cancer drugs be reviewed by the pharmacist before the drugs are dispensed.
Finally, end the confusion between folic and folinic acid immediately by using only the proper name for folinic acid: leucovorin calcium.