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ISMP Medication Safety Alert


FAMILY INTERVENTION SAVES A LIFE

Families, caregivers, and patients can usually be a last, best safety check for their own medication use. Nowhere is this easier to see or more important than in the recent case of a renal transplant patient who was released from the hospital with a home IV.

The patient needed to receive the drug Abelcet®, a newer drug whose unusual IV dosages can be easily confused with older, more well-known drugs. Unfortunately a pharmacist who was not familiar with the newer drug and its unconventional dosages filled this drug order. As a result, the patient got an overdose of the drug that was more than three times the normal dosage for this medication. This serious medication error might easily have caused a tragic death if not for aggressive action by an alert caregiver.

Before the IV was started in the patient's home, his wife questioned the fact that the fluid in the IV bag was much darker in color than it had been when her husband had received the drug in the hospital. In response to her question, a home health pharmacy staffer confirmed that the correct drug was being administered and the IV was started. After an hour the patient began to shake violently with chills, nausea, vomiting, and diarrhea. The wife telephoned another question to the pharmacy and was told that these were common side effects. She was told to reduce the amount of drug her husband was receiving.

When the patient's side effects didn't improve more 90 minutes after reducing the dose, the patient's wife simply stopped the therapy and re-contacted their physician. This timely action may well have saved her husband's life. It also underscores how important it is for patients and their caregivers to be alert to differences in drug therapy and reactions to drugs, and to question health care providers aggressively about all medication use.

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