The Pharmaceutical Journal
Vol 278 No 7437 p131
3 February 2007

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Letters to the Editor

Renal pharmacy

Read drug information carefully

From Ms A. Seoighe

Many of your readers are familiar with “The renal drug handbook” compiled by the UK Renal Pharmacists Group and use it as a gold standard reference source to suggest doses of drugs in renal impairment. This is an excellent reference and a precious resource for many pharmacists, but I must point out how the layout of a monograph contributed to a medication error because some vital information was missed by a pharmacist when giving advice on dosage of teicoplanin.

This incident involved an intensive care patient on continuous veno-venous haemodiafiltration (CVVHD). After reading the teicoplanin monograph in the handbook, the pharmacist recommended a dose of 400mg every 72 hours.

The handbook guided the pharmacist to recommend that dose in the following way:

Dose in CVVHD — “Unknown dialysability. Dose as in GFR=10–20ml/min”

Dose in GFR = 10–20 ml/min — “Give 30% of normal dose daily or 100% every 72 hours”

What the pharmacist did not see straight away was the vital information under the “Other information” section: “For patients with impaired renal function reduction in dose not required until fourth day of therapy. Measurement of serum levels may help.” The patient missed two days of therapy, with unknown consequences and was subsequently switched to a different antibiotic. Had all of the dosage information been included under the heading “Dose in CVVHD” it is unlikely this error would have occurred.

The editors of the book have been informed. In the meantime, all of our in-house books have been annotated to avoid such an error recurring. Perhaps readers who use this reference would benefit from doing the same.

The important message is that vital information that can influence clinical decisions may be missed if the whole monograph is not read carefully.

Anna Seoighe
Drug Safety Co-ordinator
Adelaide and Meath Hospital,
Dublin, Ireland

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