title: Dose switch to another dosage form of Neoral increase the risk of medication error?
abstract: BACKGROUND
  One of the most significant ways to avoid medication errors is to study the errors that have occurred in other institutions and to use the information to prevent similar accidents at other practice sites.
  
  
  METHODS
  We report a cyclosporine overdose that was caused, in part, by misinterpretation of the medication order of a transplanted patient. In transplantation regimen, a 15 mg BID dose of cyclosporine was supposed to be given as part of the immunosuppressive therapy. Unfortunately the patient received a total of 1500 mg but survived the overdose.
  
  
  CONCLUSIONS
  This case should be considered in the development of strategies to prevent unfavorable outcomes resulting from such errors.
authors.affiliation: Clinical Pharmacy Department, Pharmacy School, Shahid Beheshti University, M.C., Tehran, Iran.
authors.forename: Fanak
authors.initials: F
authors.lastname: Fahimi
authors.forename: Shadi
authors.initials: S
authors.lastname: Baniasadi
authors.forename: Katayoun
authors.initials: K
authors.lastname: Najafi Zadeh
mesh_terms: D016572:Cyclosporine / Q000008:administration & dosage / Q000506:poisoning*; D004334:Drug Administration Schedule; D062787:Drug Overdose / Q000188:drug therapy; D011307:Drug Prescriptions; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D012306:Risk
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine