Dose switch to another dosage form of Neoral increase the risk of medication error?
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.
Fahimi
Fanak
F
Clinical Pharmacy Department, Pharmacy School, Shahid Beheshti University, M.C., Tehran, Iran.
Baniasadi
Shadi
S
Najafi Zadeh
Katayoun
K
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
D007166:Immunosuppressive Agents; D016572:Cyclosporine