The perils of protocols: acute phosphate nephropathy after intravenous phosphate replacement

Protocols are commonly used in the hospitals around the world and enable health care organizations to put evidence into practice and provide a framework for the management of the individual patient. Such standardization of practice is felt to reduce variations in practice and improve quality of care. However, the protocols have advantages and disadvantages. I present a case where activation of the protocols for "Electrolyte, phosphate and magnesium replacement" at the time of admission to the hospital, resulted in harm to the patient because of inappropriate timing of the test(s) with a resulting action to correct the expected laboratory abnormality. Timing of tests and administration of various medications including antibiotics in hospitalized dialysis patients is important, and both the physicians and the nursing staff require vigilance when requesting/performing tests and ordering/administering medications to dialysis patients.