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A patient who'd just had a kidney transplant was transferred from the operating room to the intensive care unit (lCU). Her doctor ordered the immunosuppressive drug cyclosporine (Sandimmune) to be given orally according to the established protocol. The drug was dispensed and administered as ordered.
After 36 hours, the patient was transferred to the renal unit. Her medications were sent with her. When the renal nurse looked at the container labeled cyclosporine, she realized immediately something was wrong. Since she'd given the drug before, she knew it was available only as an I.V. injectable or an oral solution. This bottle contained tablets.
The nurse took the tablets to the pharmacist, who identified them as cyclandelate (Cyclospasmol) tablets, given to patients who have peripheral vascular disorders. She then called the patient's doctor and told him what had happened. He reordered the cyclosporine and told her to begin giving it immediately. Although the patient was at serious risk for organ rejection, the correct drug was given in time to prevent it.
This error was caused when a pharmacist confused the names cyclosporine and Cyclospasmol and dispensed the wrong drug. Because the lCU nurses were unfamiliar with cyclosporine, a fairly new drug, they didn't know its only oral form was liquid.
So be sure you know the drugs you administer. Before giving an unfamiliar drug, look it up in a drug reference. Remember: You're the last line of defense against medication.