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