Poor communication dynamics among health care practitioners can hinder recognition of medication errors.

Continued persistence in communicating recognized problems, even when faced with oppostion from experts, often results in correcting errors before they reach patients.

Such was the case recently when an attending physician ordered pegaspargase intravenous (IV) (Oncospar) for an acute lymphoblastic leukemia patient who had previously developed an allergic reaction to asparaginase (Elspar). Pegaspargase is used solely for patients who have developed hypersensitivity to asparaginase. The preferred route of administration is intramuscular (IM); the intravenous route increases the incidence of cross-reactivity in asparaginase-sensitive patients and the possibility of liver toxicity, coagulopathy and gastrointestinal and renal disease.

Before pegaspargase became available in 1994, an asparaginase desensitization protocol was commonly used to treat patients with hypersensitivity by rapidly administering the drug intravenously, beginning with one unit and doubling the dose every 10 minutes until the total accumulated dose equals the planned daily dose. In this case, the physician ordered pegaspargase IV with a dosing schedule similar to that for the asparaginase desensitization regimen, rather than a single IM dose as indicated for pegaspargase.

To clarify the order, the pharmacist called the attending physician, who was reluctant to change the order since he had reviewed its contents with the director of the protocol under which this drug was being used. When the protocol director was called, he confirmed that he had suggested using the asparaginase desensitization routine with pegaspargase. Further persistence by the pharmacist identified that the protocol director was unaware of the risks of administering pegaspargase IV and had never before prescribed it using a desensitization routine. He simply thought it would be the safest thing to do. All eventually agreed that the drug should be administered as a single IM dose.

The ISMP comments that, in many cases, reports of lethal errors involved situations in which orders were questioned but not changed.

This often results when practitioners are intimidated into carrying out what may be a dangerous order or are easily convinced that an order is safe. In the case cited above, an experienced pharmacist was able to resolve the issue only through patience, persistence and trusting his own expertise. The ISMP encourages questioning of orders when there is a reason to believe that a patient is at risk, or when there is a sense of “something wrong”, even when it means challenging experts. Caution should be used when presented with what may appear on the surface to be “evidence” that the order is accurate and safe.

Reference: ISMP Medication Safety Alert!, Vol. 4, Issue 4, 24 February 1999.