A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythema. The ED physician made the diagnosis of cellulitis and prescribed vancomycin, 1 g IV every 12 hours. The patient's first dose was administered in the ED.
Approximately 6 hours after admission to the ED (and just 3 hours after receipt of his first vancomycin dose), the patient was transferred to a medical–surgical floor. The admitting nurse noted the vancomycin order on the admission order set and—unaware that the patient had received a dose in the ED—administered another dose.
Physicians may write "delayed admission orders" that are activated upon ward admission. However, in patients with longer ED stays, some of those delayed admission orders are carried out in the ED. In this instance, the respective ED and ward systems were not linked, limiting tracking of medication administration in the respective units. Similarly, the pharmacy system at this hospital did not capture outpatient versus ED versus ward dispensing of medications.
A physician who was aware the patient had received a dose of vancomycin in the ED realized the mistake and ordered a serum vancomycin level. While the patient was confirmed to have an elevated level, he experienced no associated toxicities, and his dosing resumed on the appropriate schedule.
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