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Cases & Commentaries
- Web M&M
Annie Yang, PharmD, and Lewis Nelson, MD; September 2016
Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.
Journal Article > Review
The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action.
Reed BN, Fox ER, Konig M, et al. Am Heart J. 2016;175:130-141.
Patients hospitalized with cardiovascular conditions are particularly vulnerable to medication errors. This review explains how drug shortages associated with cardiovascular medications pose risks to patients and provides recommendations for clinicians, policymakers, and manufacturers to address this problem.