The physician ordered the methotrexate as listed: A wrong dose near-miss

An 85-year-old man who'd been getting treatment for severe psoriasis was admitted to the hospital with a three-week history of confusion, forgetfulness, and weakness. Home medications listed on his medication reconcilation sheet included oral methotrexate, 25 milligrams every Saturday at breakfast and lunchtime. The hospital used patients' medication reconciliation sheets as order sheets, and a physician ordered the methotrexate as listed.

A typical dose of methotrexate for psoriasis is 2.5 milligrams at 12-hour intervals for three doses once a week. Doses may be gradually adjusted but generally should not exceed 30 milligrams/week. The pharmacist recognized that a 50 milligram weekly dose was high, so he asked the nurse to confirm it. The patient verified that he was taking 25 milligram doses.

Before dispensing any methotrexate, a second pharmacist questioned the order. The pharmacist called the patient's family and asked them to read the prescription container. It indicated that each dose was supposed to be 2.5 milligrams. The order was changed because of the pharmacy intercept, and the patient received the correct dose.

Advice: Bring your medication containers and a list of your medications when you go to the hospital.

Read another near-miss of a drug error story.

Thanks to Michael Cohen for the source story in the June issue of Nursing2008.