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Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis

Medication error is one of the important causes of preventable adverse drug reactions. It can occur in the form of administration of a wrong drug, in the wrong dose, to the wrong patient, in an unsuitable dosage form, for the wrong duration or by using an inappropriate route of administration. Intra...

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Autores principales: Surendiran, Adithan, Kaku, Mayur V., Adithan, Chandrasekaran
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Medknow Publications & Media Pvt Ltd 2012
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271517/
https://www.ncbi.nlm.nih.gov/pubmed/22345885
http://dx.doi.org/10.4103/0253-7613.91883
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author Surendiran, Adithan
Kaku, Mayur V.
Adithan, Chandrasekaran
author_facet Surendiran, Adithan
Kaku, Mayur V.
Adithan, Chandrasekaran
author_sort Surendiran, Adithan
collection PubMed
description Medication error is one of the important causes of preventable adverse drug reactions. It can occur in the form of administration of a wrong drug, in the wrong dose, to the wrong patient, in an unsuitable dosage form, for the wrong duration or by using an inappropriate route of administration. Intradermal skin testing for cloxacillin hypersensitivity is done at low doses to check for drug allergy. In this report, three patients were given 50 times higher dose of cloxacillin than recommended for skin testing, resulting in pain and necrosis at the site of injection. The error occurred due to wrong dilution of the drug as done by a nursing intern. Some reasons for this could be overtime working, under trained staff, unsupervised nursing interns, complicated and unclear protocols, interpersonal communication gap between health care professionals and also poor availability of ideal resources. Pharmacovigilance centers must alert health care professionals about the significance of reporting medication errors through bulletins and journals.
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spelling pubmed-32715172012-02-15 Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis Surendiran, Adithan Kaku, Mayur V. Adithan, Chandrasekaran Indian J Pharmacol Drug Watch Medication error is one of the important causes of preventable adverse drug reactions. It can occur in the form of administration of a wrong drug, in the wrong dose, to the wrong patient, in an unsuitable dosage form, for the wrong duration or by using an inappropriate route of administration. Intradermal skin testing for cloxacillin hypersensitivity is done at low doses to check for drug allergy. In this report, three patients were given 50 times higher dose of cloxacillin than recommended for skin testing, resulting in pain and necrosis at the site of injection. The error occurred due to wrong dilution of the drug as done by a nursing intern. Some reasons for this could be overtime working, under trained staff, unsupervised nursing interns, complicated and unclear protocols, interpersonal communication gap between health care professionals and also poor availability of ideal resources. Pharmacovigilance centers must alert health care professionals about the significance of reporting medication errors through bulletins and journals. Medknow Publications & Media Pvt Ltd 2012 /pmc/articles/PMC3271517/ /pubmed/22345885 http://dx.doi.org/10.4103/0253-7613.91883 Text en Copyright: © Indian Journal of Pharmacology http://creativecommons.org/licenses/by-nc-sa/3.0 This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Drug Watch
Surendiran, Adithan
Kaku, Mayur V.
Adithan, Chandrasekaran
Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title_full Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title_fullStr Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title_full_unstemmed Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title_short Medication error – Inadvertent high dose intradermal cloxacillin induced skin necrosis
title_sort medication error – inadvertent high dose intradermal cloxacillin induced skin necrosis
topic Drug Watch
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271517/
https://www.ncbi.nlm.nih.gov/pubmed/22345885
http://dx.doi.org/10.4103/0253-7613.91883
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