ISMP Medication Error Report Analysis

摘要

A hospital recently experienced 2 errors involving a mix-up between leucovorin and levoleucovorin (Fusilev). An order was written for levoleucovorin, but a pharmacy technician incorrectly pulled leucovorin from stock and prepared that instead. The drug was correctly labeled leucovorin, but the error was not caught by pharmacy or nursing and the drug was administered to the patient. Due to name similarity, there is significant potential for dosing errors when leucovorin and levoleucovorin are interchanged. This is an important error, because the dose of levoleucovorin is one-half the dose of racemic leucovorin injection (leucovorin). In this case, 400 mg/m2 leucovorin would be similar to 200 mg/m2 levoleucovorin.Since the error, the hospital pharmacy has separated the 2 drugs in their automated dispensing cabinets (ADCs) and instituted tall man lettering for the ADC software listings. However, the drug information database used by the hospital for its computer order entry processing does not allow tall man lettering.