This month we look at how one medication error, which could have been identified numerous times, went unnoticed until it was too late.

Dr. P, 42, was a nephrologist who had a private practice in a large medical arts building. Many of his patients were referrals from other physicians who worked in the building. One such referral was Mr. W, 50. The patient had been referred to Dr. P for renal insufficiency. Mr. W had a history of ankylosing spondylitis and scleroderma. He had an elevated serum creatinine, low creatinine clearance, anemia, and proteinuria. He had previously been prescribed 5mg of prednisone daily for treatment of his renal disease.

After the physician examined the patient and went over the lab work, he felt there was no evidence of acute sclerodermal crisis that would account for Mr. W’s kidney failure. Dr. P decided to put the patient on an ACE inhibitor and see if that improved the situation.

After ten weeks, and two more office visits, Mr. W’s creatinine failed to improve and proteinuria was still significant. Dr. P continued to monitor the patient for several more weeks. In the meantime, he increased the daily prednisone dose to 10mg.

Unfortunately, the patient’s kidney function was not improving. At their next appointment, Dr. P discussed with Mr. W the possibility that kidney dialysis would be necessary. The patient became very agitated and told the physician that he did not want to go on dialysis because he believed it would interfere with his ability to work. Dr. P agreed to try to avoid dialysis, but warned the patient that it might become necessary.

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At the next appointment, with the patient’s kidney function continuing to deteriorate, the doctor decided to put the patient on 120mg of prednisone every other day to see if renal function would improve. He sent an email to his nurse, Ms. N, stating “Kidney function is slightly worse. As a last-ditch effort to keep him off dialysis we need to have him take prednisone 120mg every other day.” Then Dr. P left for a much needed 10-day vacation.

The next day, Ms. N called in the prescription to the pharmacy, but mistakenly ordered 120mg of prednisone every day rather than every other day. She then completed the medication summary in the patient’s chart to reflect 120mg daily.