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A patient discharged after a cholecystectomy developed a wound infection and had to be readmitted. His doctor ordered antibiotics for the infection, Demerol (meperidine) for severe pain, and Tylenol (acetaminophen) for less severe pain.
When the patient's condition improved and his pain decreased, the doctor discontinued the Demerol and ordered Tylenol with Codeine No.2, two tablets q4h, in its place. He forgot that his original order for Tylenol, 325 mg, two tablets q4h, hadn't been discontinued.
The nurse who transcribed the Tylenol with Codeine No. 2 order didn't see the original order for Tylenol because it was on a separate medication sheet. So for 10 days the patient received two tablets of regular Tylenol and two tablets of Tylenol with Codeine No. 2 (which contains 300 mg of acetaminophen per tablet) every 4 hoursa daily dose of 7,500 mg of acetaminophen.
The patient's doctor discovered the error when routine laboratory tests showed elevated liver enzymes. Screening the patient's medication administration record (MAR) for a clue, he found the double doses. The doctor immediately discontinued both Tylenol orders and ordered the patient's liver function monitored daily. Luckily, the enzyme levels returned to normal within a week.
The doctor erred by not reviewing the patient's current medications when ordering the Tylenol with Codeine No.2. But the patient's nurses bear some of the blame as well-not one questioned the duplication of doses. To prevent such errors, review the patient's MAR whenever a new drug is ordered. And when administering drugs, keep alert for duplications.