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Check frequency Even when the correct drug has been prescribed, patients can come to harm if it is given at an inappropriate dose or frequency. We have encountered several cases in which a loading dose of digoxin was inadvertently continued as a maintenance dose. There have been similar cases with phenytoin. Some drugs require particular care. Unfortunately there


have been several public cases of methotrexate toxicity, in which patients have received the drug daily instead of every three days. Similar errors have also occurred with bisphosphonates being prescribed daily rather than weekly. Such errors are more likely to occur when drug charts are re-written or amended and therefore doctors should take extra care to not only check the name of each drug is correct, but also that it has been prescribed in the correct frequency.


Confirm route Many patients in hospital require complex medical care, which may include the administration of drugs by different routes. It is important to include a route of administration for every drug you prescribe and ensure the dosage is appropriate for that route of administration. The importance of ensuring the correct route of


administration is perhaps best highlighted by the chemotherapy drug vincristine. There have been several cases in which this drug, which should be administered intravenously, has been incorrectly delivered intrathecally with fatal consequences. Although numerous safeguards have been developed to try and eliminate the risk of this error, it has continued to occur and highlights the importance of the doctor being extra vigilant.


Consider drug interactions Many patients in hospital have complex co-morbidities


requiring numerous medications. It is worthwhile checking a patient’s existing medicines before prescribing anything new. Consider whether the effects of one drug may be affected by the addition of another, or whether the combination may pose a greater risk of adverse effects to the patient. We have seen several cases of patients on warfarin reaching dangerous levels of anticoagulation due to the addition of an interacting antibiotic.


Don’t be afraid to seek help Remember you are not alone. In addition to the national and local formularies, you should take advantage of the knowledge and experience of those around you. The ward pharmacist will be able to provide valuable advice on dosing regimens and possible drug interactions. You should also ask senior colleagues to clarify any drugs they ask you to prescribe which are unfamiliar. Remember they were also trainees at one stage and no one expects you to know everything about every drug.


Dr Naeem Nazem is a medical adviser at MDDUS


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