Hazards of Loading Doses
An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level. Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, MD, both of the University of Illinois Hospital and Health Sciences System, describe risks associated with loading doses and advocate for clear communication, verification, and documentation to avoid confusion.
Hazards of Loading Doses | AHRQ Patient Safety Network