Abstract

To the Editor: Because of the significant interaction between quinolone antimicrobial agents and several divalent or trivalent cations, 1–4 we recently changed our computer-generated nurses’ medication administration report (MAR) to schedule quinolones automatically 2 hours before products with these cations. Although we had previously included a preprinted note to the nurses on the MAR that administration of quinolones should be spaced 2 hours before these cations, it was not effective in changing nurses’ behavior. Consequently, after receiving Pharmacy & Therapeutics Committee approval to have appropriate scheduling automatically, we thought that the problem was solved. For example, once-daily levofloxacin was scheduled in the computer at 6 am by default; therefore, the medication would be administered at the time printed on the MAR. Much to our dismay, we recently noted that a night shift nurse withheld the 6:00 am dose until 8:00 am to avoid waking the patient (thus ensuring coadministration with a scheduled magnesium product and breakfast, which is usually high in calcium). We wonder how many other hospitals have developed similar solutions to this problem but forgot to look at the MAR. Upon this discovery, we conducted a nursing inservice program further explaining the highly significant nature of these interactions (eg, 85% reduction in bioavailability of ciprofloxacin with the same administration time as 30-ml magnesium-aluminum antacid, 2 90% reduction in bioavailability of ciprofloxacin with sucralfate 3). Our point obviously has much larger implications than this one drug interaction. Despite advancing technology that continually facilitates improved patient care, health care professionals still ultimately must scrutinize the MAR to determine exactly when and if medications have been administered. We hasten to add that we admire and respect our nurse colleagues. They are absolutely essential members of the health care team, and most of our nurses are highly skilled and conscientious. We acknowledge that the worsening nurse shortage adds to this dilemma, so that doses are not always administered as scheduled. 5 If each member of the health care team continues to work with colleagues and shares clinically relevant information, patient care will improve, including optimal administration times to avoid potential subtherapeutic response.Amy M. Redmond, PharmDJohn M. Norwood, MDNaseem Amarshi, PharmDTimothy Self, PharmD