Medication Error in a Busy Ward
A 65-year-old man with hypertension and chronic kidney disease (eGFR 30 mL/min/1.73 m²) is admitted to a medical ward with pneumonia. He is prescribed ceftriaxone 1 g IV daily and gentamicin 5 mg/kg IV daily. The nurse is about to administer the gentamicin when she notices that the prescription was written by a newly qualified doctor who did not adjust the dose for renal function. The patient's weight is 70 kg, so the prescribed dose is 350 mg. The hospital formulary states that gentamicin should be dosed at 5 mg/kg/day but with dose adjustment in renal impairment (e.g., reduced frequency or dose). The nurse has limited experience with renal dosing and is unsure whether to give the drug or clarify the order. The doctor is off the ward attending a meeting.
1. What should the nurse do in this situation, and what are the potential consequences of administering the prescribed dose?
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The nurse should withhold the gentamicin and clarify the order with the prescriber or a more experienced colleague (e.g., senior nurse, pharmacist, or on-call doctor). Administering a potentially nephrotoxic and ototoxic drug at a dose not adjusted for renal impairment could cause serious harm.
Potential consequences of giving 350 mg gentamicin to a patient with eGFR 30 include:
- Nephrotoxicity: further decline in renal function, possibly acute kidney injury.
- Ototoxicity: damage to the vestibular and cochlear apparatus, causing hearing loss and balance problems.
- Neuromuscular blockade: rare but possible with high levels.
The nurse's action should include:
- Not administering the drug until the order is verified.
- Contacting the prescriber or the on-call physician to discuss renal dosing.
- Documenting the intervention and the reason for withholding the drug.
- Monitoring renal function (creatinine, urine output) and serum gentamicin levels if available.
- Advocating for the patient by ensuring safe medication practice.
Rationale: Nurses have a professional and legal duty to administer medications safely. When in doubt, it is the nurse's responsibility to question the order. The prescriber may have made an error, and the nurse's action prevents harm.
2. If the doctor cannot be reached and the patient's condition requires antibiotic therapy, what alternative actions could the nurse take?
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If the doctor is unreachable and the patient needs antibiotics urgently, the nurse should:
- Consult the hospital pharmacist for advice on renal dosing of gentamicin or alternative antibiotics.
- Follow hospital protocols for medication clarification, which may allow a senior nurse to adjust the dose under specific guidelines or to administer a safer alternative if authorized.
- Consider whether ceftriaxone alone is sufficient for the pneumonia, as it is already prescribed and does not require renal adjustment. The nurse should not change the prescription independently but can discuss with the pharmacist or senior clinician.
- Escalate to the nurse in charge or the medical officer on call if the prescriber is unavailable.
- Document the situation and the steps taken.
Rationale: Patient safety is paramount. The nurse must act within their scope of practice and hospital policy. Administering a drug with a known dosing error is not acceptable. Seeking expert advice and using available resources ensures safe care.