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Source:

Nursing2015

February 2005, Volume 35 Number 2 , p 18 - 19

Author

  • MICHAEL R. COHEN RPH, MS, ScD

Abstract

© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(2)             February 2005             p 18–19 A rare event [MEDICATION ERRORS: LOMUSTINE DOSING]

COHEN, MICHAEL R. RPH, MS, ScD

President of the Institute for Safe Medication Practices

Some patients with brain cancer or Hodgkin's disease receive oral lomustine (CeeNU, 130 mg/m 2 ) once every 6 weeks to destroy cancer cells. A patient admitted to the hospital for a laparoscopic procedure was to receive her usual 140 mg dose of lomustine the day after admission. Her oncologist ordered a single dose, but the pharmacist mistakenly entered it as a daily dose, which appeared on the nurse's computer-generated medication administration record (MAR).

The patient had been receiving the drug for 5 days when routine lab tests detected severe thrombocytopenia, azotemia, and neutropenia. By then, she'd developed a fever, ...

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