"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.
- The patient is "on this medication at home."
- "A specialist prescribed it."
- The patient has been "titrated up to that dose."
- This is a "special case."
- The patient is "on a protocol."
- The drug/dose was "recently published" or from
a "published study."
- I got the order from the patient's "prior medical
- "Mom (or the patient) said they take it this way."
- It was "on a list of medications that the patient
- "We always give it that way."