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An 8-year-old girl who had severe contractures from cerebral palsy was hospitalized for tendon-release surgery. The admitting nurse asked the girl's mother what medications she'd been taking at home. The mother said she gave her daughter one teaspoonful of Dilantin (phenytoin) suspension three times a day and one teaspoonful of phenobarbital twice a day.
The nurse relayed this information to the girl's doctor, who wrote orders for the medications to be continued in the hospital.
The girl was given 5 ml of phenytoin suspension before surgery and 100 mg of I.V. phenytoin during surgery. When she returned to the unit later that morning, she began receiving the maintenance regimen ordered by her doctor.
That afternoon, the girl started to vomit. Her nurse at first attributed this to the anesthetic administered during surgery. But when she was still vomiting the next day, the nurse became concerned and decided to investigate.
As soon as she checked the child's medications, the nurse realized what was causing the vomiting. The label on the bottle of phenytoin suspension read 125 mg/5 ml. The nurse then looked up the drug and found out that it was available in two concentrations--one for adults and one for children-and that the pediatric concentration was only 30 mg/5mI.
The nurse told the girl's doctor what she'd discovered. He immediately ordered a phenytoin blood level measurement and had the drug discontinued. The test results confirmed the nurse's suspicions: The girl's phenytoin level was 28 mglliter-in the toxic range.
The girl's blood was tested daily until the concentration of phenytoin returned to a therapeutic level, at which time the maintenance regimen was resumed. Luckily, the girl developed no other toxic effects than the vomiting. But she did have to spend an additional 3 days in the hospital.
This error could have been avoided if: