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"Magic words" or "red flags?"

From the February 24 , 1999 issue

PROBLEM: Poor communication dynamics among health care practitioners can hinder recognition of medication errors. Yet, continued persistence in communicating recognized problems, even when faced with opposition from experts, often results in correcting errors before they reach patients. Such was the case recently when an attending physician ordered pegaspargase (ONCOSPAR) for an acute lymphoblastic leukemia patient who had previously developed an allergic reaction to asparaginase (ELSPAR). Pegaspargase, marketed since 1994, is used solely for patients who have developed hypersensitivity to asparaginase. The preferred route of administration is IM; the IV route increases the incidence of cross-reactivity in asparaginase sensitive patients and the possibility of liver toxicity, coagulopathy and gastrointestinal and renal disease. Before pegaspargase, an asparaginase desensitization protocol was commonly used to treat patients with hypersensitivity by rapidly administering the drug IV, beginning with one unit and doubling the dose every 10 minutes until the total accumulated dose equals the planned daily dose. In this case, the physician ordered pegaspargase IV with a dosing schedule similar to that for the asparaginase desensitization regimen, rather than a single IM dose as indicated for pegaspargase.

To clarify the order, the pharmacist called the attending physician, who was reluctant to change the order since he had reviewed its contents with the director of the protocol under which this drug was being used. When the protocol director was called, he confirmed that he had suggested using the asparaginase desensitization routine with pegaspargase. Yet, further persistence by the pharmacist identified that the protocol director was unaware of the risks of administering pegaspargase IV and had never before prescribed it using a desensitization regimen. He simply thought it would be the safest thing to do. As such, all eventually agreed that the drug should be administered as a single IM dose.

SAFE PRACTICE RECOMMENDATION: In many cases, reports of lethal errors received by the USP-ISMP Medication Errors Reporting Program have involved situations in which orders were questioned but not changed. This often results when practitioners are intimidated into carrying out what may be a dangerous order or are easily convinced that an order is safe. In the case cited above, an experienced pharmacist was able to resolve the issue only through patience, persistence and trusting his own expertise, not above that of others, but to augment the expertise of others. Still, how many of us, particularly early in our careers, would have challenged seemingly unimpeachable sources such as a protocol director or oncologist? Don't be afraid to question orders when you have reason to believe that a patient is at risk, or even if you just have a sense that "something" is wrong. Use caution when presented with what may appear on the surface to be "evidence" that the order is accurate and safe.

Our colleague, Timothy Lesar, of Albany Medical Center, Albany, New York, has collected a list of phrases, or "magic words" that often have been erroneously accepted as "evidence" when used to convince practitioners to carry out questionable orders (See table 1 below). Consider these and like comments "red flags" that require more reliable answers or evidence in hand. Also establish procedures that clearly identify the steps a practitioner should take when there is disagreement about the safety of an order. Finally, when doubting your own knowledge and expertise, ask yourself: Which would be worse - the possibility of being wrong or the possibility of injuring a patient? Practitioners whose lack of persistence resulted in patient injury sorely wish they had risked being wrong and continued to ask questions until the issue was fully resolved.

Table 1.
  1. The patient is "on this medication at home."
  2. "A specialist prescribed it."
  3. The patient has been "titrated up to that dose."
  4. This is a "special case."
  5. The patient is "on a protocol."
  6. The drug/dose was "recently published" or from a "published study."
  7. I got the order from the patient's "prior medical records."
  8. "Mom (or the patient) said they take it this way."
  9. It was "on a list of medications that the patient gave me."
  10. "We always give it that way."
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