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The check, please!

From the April 21, 1999 issue

PROBLEM:: ISMP often encourages prescribers to include in written orders the mg/kg or mg/m2 dose along with the calculated drug dose as an effective error prevention strategy for geriatric, pediatric and oncology patients. Thus, an independent calculation can easily confirm accuracy. However, unless practitioners recalculate the dose to verify accuracy, the prescriber's extra effort is wasted. A recent error caused a significant overdose of methylprednisolone even though the prescriber included the mg/kg dose. After an 80-year-old patient was admitted to the hospital for cervical neck surgery, a prescriber, who was a physician assistant, wrote an order for "methylprednisolone 10.6 g (30 mg/kg) over one hour IVPB prior to surgery." The patient weighed about 70 kg. However, neither the pharmacist who entered the order into the computer system, nor the nurses who transcribed the order and administered the medication, independently checked the prescriber's calculated dose. Had they done so, they would have identified that the correct dose was 2.1 g, not the ordered dose of 10.6 g. Additionally, the same prescriber wrote a second order for "methylprednisolone 1.7 g (5.4 mg/kg) over 8 hours IVPB intra-op and post-op." In this case, the correct dose was 5.4 mg/kg/hr. However, the prescriber did not include the per hour designation. Thus the total calculated dose was incorrect. Again, the pharmacist and nurses did not verify the dose calculation. Had they done so, they would have identified that the correct dose was about 3 g (not 1.7 g) infused over 8 hours. The surgeon discovered both errors later that day when he cosigned the physician assistant's orders. Still, the patient had already received a massive overdose from the initial infusion which resulted in significant hyperglycemia (blood sugar over 420) and hypokalemia (potassium level of 3.4). The patient was monitored for additional adverse effects and recovered without injury.

SAFE PRACTICE RECOMMENDATION: All prescribers should be encouraged to include the mg/kg or mg/m2 dose upon which they base the calculated drug dose. Just as important, pharmacists and nurses must take responsibility for independently double-checking the calculated dose mathematically rather than just "eyeballing" it. Practitioners should also initial the order to show that they have verified the dose. Additionally, these errors might have been detected during order entry if the pharmacy computer system had been structured to include warnings for doses that are either subtherapeutic or that exceed established maximum dose guidelines.

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