Error Number 85. skimming over medication orders without checking for discrepancies

A doctor wrote an order for gentamicin, 80 mg, to be given intramuscularlyevery 12 hours to a 55-year-old woman hospitalized for pneumonia. The unit secretary transcribed the order as follows:

A medication nurse checked and approved the transcription without noticing the discrepancy between "every 12 hours" and the designated administration times, which are every 8 hours. For 5 days, the patient was given the antibiotic every 8 hours. On the fifth day, a nurse discovered the error and notified the patient's doctor. He ordered tests to determine the serum levels of genta¬micin. As expected, they were in the toxic range.

The drug was discontinued immediately, and the patient's blood was monitored until the drug levels returned to normal. Thankfully, the error was caught before the patient developed nephrotoxicity or ototoxicity.

To prevent such an error, read medication order transcriptions in their entirety and check for discrepancies before administering a drug. Don't allow medication administration to become a mindless task.