July 2004, Volume 34 Number 7 , p 12 - 12
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(7) July 2004 p 12 “Pro” moting safety [MEDICATION ERRORS: NAME CONFUSION]
COHEN, MICHAEL R. RPH, MS, SCD
A prescriber ordered the proton pump inhibitor Protonix (pantoprazole), 40 mg I.V. daily, for a patient with gastrointestinal (GI) bleeding. The order was poorly written, and the unit secretary entered it in the computer as protamine (a heparin antagonist), 40 mg I.V. daily. A pharmacist discovered the error.
In another case, a nurse transcribed a verbal order for protamine, 40 mg I.V. push, but a pharmacist misinterpreted the handwritten entry as Protonix, 40 mg I.V. push. When the pharmacist called to tell the nurse he'd be sending a piggyback infusion (Protonix shouldn't be administered by I.V. push), the nurse clarified the order.
Mix-ups between Protonix and protamine not only ...