April 2005, Volume 35 Number 4 , p 10 - 10
© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(4) April 2005 p 10 Weigh the dangers [MEDICATION ERRORS: ORDERING BY VOLUME]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A nurse transcribed a verbal order for a weekly subcutaneous dose of methotrexate, an antimetabolite. Because the dose was expressed as “0.7 ml (25 mg),” the pharmacist questioned the order. The prescriber clarified that the patient was supposed to receive 0.7 ml of the 25 mg/ml strength. The prescriber should have ordered 17.5 mg.
Ordering by milliliters, teaspoons, tablespoons, or other volumes rather than metric weight (milligrams or micrograms) is risky. If you receive such an order, call the prescriber for clarification.
The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting ...