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Monday, December 11, 2006

Medical Error of the Week: Too Much of a Good Thing

Mr. A., a bearded, pleasant-looking married man of 47 with three children, loved to eat. His weight had become alarming, and he had gotten diabetes. Four years ago, he had had gastric bypass surgery to reduce his weight; he lost more than 100 pounds--and his diabetes. Two years ago, he developed a hernia (a protrusion through the abdominal wall), which was repaired surgically. To speed the healing of the surgical site, his surgeon prescribed multi-vitamins, with a zinc supplement. However, the four-inch wound didn’t heal, even after intravenous antibiotics in the hospital. Indeed, he became anemic—tired, and lacking red blood cells, achy, and neutropenic (having lost most of his bacteria-killing white blood cells), along with a fever. A young hospital resident [physician] determined that both his anemia and neutropenic fever had been caused by too much zinc. The doctor told him to stop taking the zinc supplement, and he recovered fully within two months.

What was the error?
A preventable adverse drug event/adverse drug reaction to zinc. The dosage may have been too high (wrong dose). The patient might have been instructed to take the zinc for too long (wrong time).

Why did the error occur?
The surgeon had prescribed the high doses of vitamins and zinc because of evidence that they can speed healing after surgery, especially early on. However, the surgeon, the hospital doctors who treated him later, and his primary care physician did not link the complications of anemia and neutropenic fever to the zinc supplement.

Lessons for Caregivers:
Mr. A.'s wife had shown the hospital resident the list of Mr. A.'s home medications, enabling the resident to learn of and look into the role of zinc. Mrs. A had included vitamins and minerals in the list--not only medicines. She both wrote the list and brought it in to the attention of the doctor at the right time. Bravo! Please do the same for your family members.

Later this week we'll discuss more about Mr. A.; stay tuned.

This summary is drawn from Dr. Lisa Sanders’ article, “The Healing Problem,” in The New York Times Magazine, Nov. 12, 2006.

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