Nurse transcribes the order as Kayexelate. Since the order included an indication the error was caught. . There is no clear separation of nontoxic, toxic, and lethal doses of colchicine. Make sure staff understands the maximum doses.
Reader suggests that orders requiring a decimal point be written like a check to prevent errors.
For example an oreder for 1.4 mg would be written as one and four tenths mg in parenthesis so that it would be harder to confuse as 14 mg. Safety Briefs Trissel's Handbook of Injectable Drugs 10th edition now has caution statement about the potential for fatal hemolysis and acute renal failure due to the reduction in tonicity whensufficient sterile water is used as a diluent for albumin. Although the mechanism of toxicity for vinca alkaloid products administered intrathecally has not been clearly defined, autopsies on patients who received fatal doses of intrathecal vincristine have demonstrated vast CNS tissue necrosis and damage consistent with the dose limiting neurotoxicity for all the vinca alkaloids. To date, no cases of intrathecal administration of vinorelbine have been reported. To prevent this from happening, we recommend that all extemporaneously prepared syringes of vinca alkaloids, including vinorelbine, be treated identically with label warnings and packaging to act as barriers against intrathecal administration.