MEDICATION ERRORS: “Pro” moting safety

July 2004 
Volume 34  Number 7
Pages 12 - 12
  PDF Version Available!

© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(7)             July 2004             p 12 “Pro” moting safety [MEDICATION ERRORS: NAME CONFUSION]


A prescriber ordered the proton pump inhibitor Protonix (pantoprazole), 40 mg I.V. daily, for a patient with gastrointestinal (GI) bleeding. The order was poorly written, and the unit secretary entered it in the computer as protamine (a heparin antagonist), 40 mg I.V. daily. A pharmacist discovered the error.

In another case, a nurse transcribed a verbal order for protamine, 40 mg I.V. push, but a pharmacist misinterpreted the handwritten entry as Protonix, 40 mg I.V. push. When the pharmacist called to tell the nurse he'd be sending a piggyback infusion (Protonix shouldn't be administered by I.V. push), the nurse clarified the order.

Mix-ups between Protonix and protamine not only ...

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