Medicines used in chronic kidney disease | Prescription for ‘Epo’. Inappropriate abbreviation used with no brand or dose specified | Prescription is unclear and therefore nursing staff would be unable to administer the medication. As a consequence, the patient may not receive the treatment or it could lead to inappropriate delays. | Severe |
Calcium carbonate prescribed as a phosphate binder for a patient with hypercalcaemia | Exacerbation of hypercalcaemia potentially causing lethargy, weakness, confusion, coma, constipation, nausea, anorexia and arrhythmias | Severe |
Anticoagulation | Dalteparin (12 500 units once daily) prescribed for a deep venous thrombosis in a patient on haemodialysis | Low molecular weigh heparins given at conventional treatment doses to patients on haemodialysis will accumulate, which can complicate reversal of anticoagulation. | Severe |
Antimicrobials | Clarithromycin prescribed in combination with tacrolimus and atorvastatin (significant interactions) | Increased exposure to atorvastatin and tacrolimus, which could lead to myopathy (atorvastatin) and nephrotoxicity and neurotoxicity (tacrolimus) | Severe |
Wrong dose of ganciclovir prescribed (500 mg tds instead of 500 mg bd) | Increased exposure to ganciclovir, which could lead to neurotoxicity and myelosuppression | Severe |
Incorrect (too high) dose of meropenem prescribed for a patient receiving haemodialysis | Increased exposure to meropenem which could lead to neurotoxicity | Severe |
Valganciclovir unintentionally omitted from a renal transplant patient medication card when it was required | Omitting valganciclovir in these cases could result in increased risk of cytomegalovirus disease | Severe |
Immunosuppression | Treatment with mycophenolate mofetil inadvertently continued for a renal transplant patient with cytomegalovirus infection | If immunosuppression is not minimised, this could compromise the success of treatment for cytomegalovirus disease in renal transplant patients. | Severe |
New transplant patient whose medication chart did not include any immunosuppression or adjuvant agents given after renal transplantation. This patient was prescribed inappropriate medicines such as high-dose furosemide and phosphate binders (no longer indicated) | Lack of prescribed immunosuppression following renal transplantation will increase the risk of acute rejection and graft loss. | Severe |
Prograf dose prescribed as 500 mg instead of 500 micrograms | Although it is unlikely that the dose would have been given (100 capsules of 5 mg would have to be administered), this error constitutes a 1000-fold overdose which would almost certainly be fatal. | Lethal |