Just one more game

2007-01-02 - 8:13 p.m.

On Saturday, a very bad thing happened in my pharmacy. Although it didn't involve me directly (or even indirectly really), it still makes me feel horrible. A patient came into the outpatient infusion center to receive a dose of infliximab, a monoclonal antibody used most commonly for autoimmune diseases such as rheumatoid arthritis and ulcerative colitis. We mixed up an IV filled with etoposide (the wrong drug!), put the infliximab label on it, and sent it over to the OIC, where it was infused into the patient. Etoposide is not a good drug. It's a chemo drug used to treat things such as leukemia, brain cancer, lung cancer, and testicular cancer. It's one of the baddies that makes people throw up a lot and makes their hair fall out, not to mention a whole bunch of other less pleasant but also less visible side effects. This is a very horrible thing. How did it happen? The intern in the IV room grabbed the wrong label and then never read it. The pharmacist who checked it was in a hurry or distracted or somehow managed to sign off that the label on the empty vial presented to her matched the label on the completed IV. I don't know how it happened. Usually, before etoposide is administered, we give the patient some other medications to make the initial reaction to etoposide a little less unpleasant. This patient, not expecting to receive etoposide, of course didn't receive any of those pre-meds. Needless to say, she reacted badly to the etoposide. In the OIC, they had no way of knowing that the patient was receiving the wrong medication. They thought she was having an unusually rough time with the infliximab. They may have eventually guessed that the patient received the wrong drug, but they would've had no way of confirming that. How did we find out about it? We had a technician in the IV room who was very organized. She noticed one of her etoposide vials missing and none of her etoposide labels missing. She put two and two together. It's only because of her that we know a mistake was made. Our hospital has a policy of being very open about errors and not trying to cover anything up, so the patient was immediately informed of what had happened and apologized to and we did everything we could to alleviate her pain and suffering--but it's chemo, suffering is part of the package. What a horrible thing to happen to someone! Imagine going to the clinic to have something fairly benign done to you and then being infused with chemo without your knowledge! Not only that, but the dose of etoposide she received was equal to the dose of infliximab she should've received, which, while not entirely out of the realm of possibility, was a very hefty dose of etoposide. Poor, poor patient. How do you ever make that up to someone?

In other news...I was diagnosed with Thygeson's superficial punctate keratopathy today. I've been having pain in my eyes for the past three weeks. At first it was a mild burning and I attributed it to wearing contacts. But then I stopped wearing my contacts (last wore them December 14th). It was about the time we went to see Lolo's grandmother that the sharp pains started. Sharp pain, but not intolerable and I figured it was Christmas so probably my optometrist was on vacation anyway. Then the sharp pains started in the other eye and I got more concerned. This morning my eyes were hurting pretty badly at work. All the holidays are over so I called my optometrist's office and made an appointment for this afternoon. TSPK is a viral infection of unknown etiology that causes eruptions on the cornea. My eye is exploding, no wonder it hurts. First he called it Thygeson's syndrome. Later I asked him, "What's the name of the condition?" so I could get it right and he pulled out this condescending tone of voice and said, "Thygeson's superficial punctate keratopathy--there's a mouthful. I think it's named after somebody." It was the tone--I found it annoying. I said, "Mr. Superficial Punctate Keratopathy?" I think that's when he remembered I'm a pharmacist and these things might not be over my head. At any rate, he gave me a prescription for some fluorometholone eye drops and a follow up appointment next week.

And one more bad thing--I chipped my front tooth today. Not the front tooth I chipped before and had repaired. The other one. I was a bit overzealous during dinner and bit my fork. Seriously. I'm such a dork.

Oh, and did I mention that my laptop has died so I'm having to use Lolo's computer?