Medication Error Rates
March 18, 2020
Practical steps to reduce med errors
April 1, 2020

Pharmacokinetic Dosing Errors

Medication errors associated with pharmacokinetics can sometimes get overlooked. Oftentimes, dosing errors occur but may go unreported. This can be especially true when dealing with aminoglycosides. Proper dosing involves assessing the size of the dose and the frequency of administration. This makes it all too easy to miss on either the magnitude of the dose or the dosing interval or unfortunately, sometimes missing on both.

The good news is that a good clinician will make the proper adjustments. A good rule of thumb that we have had success with; if the peak is elevated, we reduce the dose and if the trough is elevated, we extend the dosing interval.

The bad news is that if the erroneous dosing is clinically significant, this can result in nephrotoxicity with a somewhat delayed bump in the serum creatinine. In addition, ototoxicity can likewise result but may substantially be delayed well after the aminoglycoside has been discontinued. As a result, the diagnosis of ototoxicity secondary to aminoglycoside dosing may go unreported and the medication dosing error is missed.

 

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