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Caught in a vicious cycleo

From the Mar. 26,1997 Issue

PROBLEM:A pharmacist received an order for cyclosporine (Sandimmune®;) 25 mg TID for a woman with a kidney transplant. The first five letters of the generic drug name were keyed into the pharmacy computer. This brought up mnemonics for drugs starting with that set of letters. Cyclosporine 25 mg was the fifth item on the screen; cyclophosphamide (Cytoxan®) 25 mg was the very first displayed. The pharmacist mistakenly accepted the cyclophosphamide 25 mg instead of the cyclosporine 25 mg, and two doses were sent to the nursing floor. That afternoon, one dose of cyclophosphamide 25 mg was given, but when it was time for the evening dose the patient's family was present. Upon seeing the drug, the patient's husband immediately noticed it was not his wife's usual medication. His comment of "she can't take regular cyclosporine, it has to be Neoral® (cyclosporine for microemulsion)" made the nurse examine the medication and the order more closely. When the nurse called a pharmacist to ask if she could get Neoral instead of cyclophosphamide, red flags were immediately raised in the pharmacy. The pharmacist checking the original order against the computer entry quickly saw that it was cyclosporine that had been ordered but that cyclophosphamide had been sent. .

The cyclophosphamide was stopped immediately and the physician was called to inform him of the error and to obtain an order for Neoral. The patient had received only one 25 mg dose which made adverse effects unlikely; however, the physician was told that increasing oral fluid intake might be beneficial to prevent hemorrhagic cystitis. Four days after the event there were no signs of any adverse effects. She continued on cyclosporine (Neoral) for the remainder of her stay

SAFE PRACTICE RECOMMENDATION: The reason for the error is, as usual, many-fold, and, although the pharmacist perhaps felt the most responsible, the error was not the fault of any one person. The physician wrote an ambiguous order; Sandimmune capsules and oral solution have decreased bioavailability compared to Neoral and, therefore, are very different even though they are both cyclosporine products. The pharmacist sent the wrong medication, perhaps misreading the order, perhaps pressing too quickly on the enter key of the computer while doing a mnemonic search. Nurses gave the medication and were about to give another dose. They assumed that pharmacy sent the right medication but they should have read the drug name and checked for themselves. Luckily for this patient, her husband noticed a difference in the appearance, called attention to it, and the nurses listened.

Steps are being taken at the hospital to avoid this type of error, but as has been pointISMP Medication Safety Alert! (n Safety Alert! (July 31, 1996), this is fairly difficult without electronic help. The computer system is being evaluated for its ability to give "warning signs" for frequent and dangerous error situations. Nurses are being reminded of their responsibility to check the medications in their hand against the order and the medication administration record. To reduce confusion, it is important for prescribers of immunosuppressive therapy to specify the brand name for cyclosporine prescriptions. [D, N, P, T]

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