Medication errors and misplaced decimal points
The potential for medication errors in the area of
neonatal medicine is of great concern. There have been several reports
of fatal errors, particularly due to 10-, 100- or even 1000-fold errors,
ie, decimal point errors, in prescribing, preparation or administration.
This problem is exacerbated by the high strength of intravenous preparations,
which are often tailored to the needs of adults. KAREN TURNER (Queen's
Medical Centre, Nottingham) presented a study which determined the proportion
of prescribed doses where the potential existed to prepare a 10-fold or
100-fold overdose from the vial strength available on the ward.
Around 33 per cent of the prescriptions were less
than or equal to one tenth of a vial, with about five per cent being less
than one hundredth of a vial. Drugs highlighted as having a high proportion
of doses in the above categories were some of the most harmful drugs in
overdose. The potential for this type of error will remain as long as
vials are manufactured with a view to treating adults. Until there is
a national demand from users for vial strengths suitable for neonates,
or pressure on the pharmaceutical industry from the licensing authorities
the potential for these errors will continue to exist.
SANDRINE ROY (Hôpital Robert Debré AP-HP, Paris)
reported a case of just such an overdose — a three-year-old boy, being
treated for acute lymphoblastic leukaemia (ALL), who received a 10 times
overdose of asparaginase in error, and his treatment with sodium benzoate.
L-Asparaginase is an enzyme that catalyses the hydrolysis of L-asparagine
to L-aspartate and ammonium. L-asparagine is an essential amino acid for
the multiplication of leukaemia cells. This enzyme is prescribed with
other cytotoxic drugs, to treat ALL and non-Hodgkin lymphomas. The main
side effect of asparaginase is neurotoxicity due to the depletion of asparagine,
required for cerebral formation, and the increase of ammonium. Sodium
benzoate, associated with glycine, has been used as an alternative way
to favour the nitrogen excretion, as hippuric acid. The child presented
no serious adverse effects and continued receiving his chemotherapy treatment
three days after overdose.
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