Medication Error Examples
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Examples Of Medication Errors In Hospitals
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DisorderCardiovascular HealthCOPDCough and ColdDiabetesEpilepsyFluGlaucomaGoutHeart FailureHepatitis CHIVInfectious DiseaseNeutropeniaOsteoporosisPain ManagementVitamins and SupplementsWomen's HealthContinuing EducationCommunityContributorsBlogsPublications Two Examples of Name-Related Medication Errors Michael J. Gaunt, PharmD Published Online: Monday, March 18, 2013 Independent verification of drug doses can prevent mix-ups and misinterpretation. http://www.pharmacytimes.com/publications/issue/2013/march2013/two-examples-of-name-related-medication-errors Chemotherapy mix-up between eribulin and epirubicin. An order for the antimicrotubular antineoplastic agent “eribulin” (eribulin mesylate, HALAVEN) was misinterpreted by a pharmacist and entered into the computer system as epirubicin, an anthracycline antineoplastic agent. Fortunately, the error was detected by a nurse when comparing the pharmacy label to the original order, and the patient did medication error not receive the wrong drug. Both drugs are associated with breast cancer treatment. Eribulin mesylate injection was approved in November 2010 for treatment of metastatic breast cancer in patients who have received at least 2 prior chemotherapy regimens that included an anthracycline and a taxane. The names above are similar enough to warrant proactive measures to examples of medication prevent look-alike or sound-alike mixups. The hospital is now applying tall man lettering and adding the salt “mesylate” to the eribulin listing in its computer systems to prevent similar errors. The drugs are now listed as eriBULin mesylate injection and epiRUBICIN injection, although the Institute for Safe Medication Practices (ISMP) would recommend EPIrubicin to prevent confusion with other anthracycline antineoplastics. A pharmacist should verify and independently recalculate the dose of any antineoplastic agent before dispensing it. In this case, the typical dosing is very different and should have prompted a call to the prescriber for verification. The dosing for epirubicin is 60 to 120 mg/m2 depending on the type of therapy the patient is receiving. The recommended dose for eribulin is 1.4 mg/m2. Incidentally, the person who reported this event mentioned that similar close calls had occurred previously in the pharmacy but were never reported through the hospital’s internal error reporting process and, therefore, no steps were taken to prevent future mix-ups. Perhaps if previous
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