A 44-year-old woman was admitted to a hospital by her orthopedist for suspected osteomyelitis after knee-replacement surgery. The antibiotic vancomycin (Vancocin, ViroPharma) was selected for treatment. The patient had also been treated for a short period with ketorolac (Toradol, Roche) for analgesia. A pharmacist calculated the vancomycin dosage (1 g every 12 hours) and recommended that blood levels be obtained at a specified time. Pretreatment serum creatinine concentrations were within normal limits. The patient s vancomycin level was subtherapeutic (7. 5 mcg/mL), and an internist was consulted. The internist increased the vancomycin dosage to 1 g every 8 hours. The pharmacist ordered another serum vancomycin analysis. The level came back at 41. 5 mg/mL. The analysis was repeated, and the result was confirmed. Serum creatinine levels were not measured to evaluate the patient s renal status after the increased vancomycin dosage, even though the vancomycin level was substantially elevated and potentially toxic. On the same day that the increased vancomycin concentration was detected, ketorolac 30 mg was administered.
None of the physicians, pharmacists, or nurses had considered that a potentially nephrotoxic drug was being administered shortly after the patient was found to have a toxic level of vancomycin. The patient was discharged home with orders to have her vancomycin level tested outside the hospital. Vancomycin was withheld, and the patient was instructed to return to the internist s office for further follow-up. At her visit to the internist, her serum creatinine level was 5. 3 mg/dL, in contrast to her levels of 0. 7 to 1. 3 mg/dL in the hospital. The patient was immediately flown to a tertiary-care hospital, where she was treated for acute renal failure and placed on hemodialysis. What is the significance of the policies in this scenario? In this case, the pharmacy s administrators had none in place for monitoring vancomycin. During the case investigation, they stated that we did not, at the time of this patient s care, monitor vancomycin patients. However, a pharmacist was writing dosage recommendations, suggesting monitoring of blood levels and pharmacokinetics and evaluating those results during the patient s hospitalization.
Yet that pharmacist denied that there was a need to monitor the patient s renal function, even in light of her toxic vancomycin level and the concomitant treatment with ketorolac, a potentially nephrotoxic drug. Other pharmacists concurred, saying we do not do vancomycin monitoring; our therapeutic drug monitoring is limited to aminoglycoside monitoring, which includes recommending and evaluating renal function tests. A pharmacist, acting as an expert witness, proposed these conclusions:
The case was resolved before trial, and the hospital adopted a policy for monitoring vancomycin after the patient s adverse event. In this case, the institution did not have a policy in place; as a result, pharmacists provided services that were not the standard of care. Even if these services were justified, each pharmacist failed to recognize a potentially toxic dose combination (vancomycin and ketorolac) and failed to advise the attending physician accordingly.
Recognizing toxic doses is a basic responsibility of pharmacists. This responsibility is consistent with federal drug utilization review (DUR) guidelines and is considered the standard of professional care by many state boards of pharmacy. The following case scenarios further demonstrate the importance of adopting and executing effective P Ps. Like all organizations, health care agencies and providers use policies and procedures to influence employee behavior. For example, a policy is a consistent guide for what employees should do in a set of circumstances. The guide offers a framework for making a decision, but should not constrain personnel to only one option in a given situation. Health care organizations must update internal policies and procedures every time new patient protocols, equipment, technologies or other innovations are adopted. With an ongoing commitment to maintaining policies and procedures, health care entities can ensure staffers make decisions and behave in desired patterns most of the time.