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Cases & Commentaries
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Jerod Nagel, PharmD, and Eric Nguyen; October 2015
A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.