Medication errors

[Aznfarmerboi]

So from my experience, medication errors happen a lot. Whenever I float at a store, I would catch errors by previous rphs. I myself have made a lot of mistakes with a few serious ones. I was wondering if you guys can tell me what your mistakes were, the outcome, how you remedy it, and what do you think were contributing factors?

For one thing, I notice that mistakes happen a lot when my techs are distracted with work and non-work related stuff especially when they multi task or chatter a lot. A good amount of my mistakes were from me not reading the entire prescription. For example, I would read Smith XXX without double checking first name or DOB, or Lexapro instead of Lexapro 10/20.

Also, in the more serious mistakes, there were definitely a few chances for me to catch the mistake. They were usually from a few bad MDs (just like how we have bad RPHs) etc. Sometimes I would be dazed... and even though I think it was werid, I would still fill a prescription because it was not "life threatening" and counseling patient would be enough to fix the "problem". That brings me to a 2nd point, patients are *******es and from my experience, they will disregard your instructions almost all the time.

I am hoping to attend a medication error CE soon but wont be able to make it to midyear. The last med error CE that I attended to was in school.

I hope you guys can share your experiences too and give me a few examples. Maybe we can all learn from it.

---

Members don't see this ad.

 

[Sparda29]

I've never had a mistake make it down to patient level. But this past weekend, I was filling a script for Enalapril 20 and Glipizide 5. I managed to count the Glipizide twice, I knew something was wrong when I found the Glipizide 5 bottle in the place of the Enalapril 20 bottle on the shelf the next time I went to count Enalapril 20.

My most common mistake results from when a patient hands me multiple prescriptions. I see the first name on the first prescription and fill it all for that person, then 5 minutes later I realize that I'm filling a prescription for an adult with a pediatric dose.

 

[GreyFox2002]

I once caught a pretty big mistake by a pharmacist I was working with. The prescription was written in cursive for Omnicef, but the handwriting was in such a way that the pharmacist punched it into the computer as Amoxicillin. It could have gone either way, I pointed it out. He called and voila, it was supposed to be omnicef. He was gracious Not a big mistake, wouldn't hurt someone, but still, wrong drug given is never a good thing.

I have made a couple mistakes in drug product selection. They've almost always involved picking an instant release instead of an extended release, or vice versa. Each time it happened I was embarassed as all hell, but its going to happen. You have to tell yourself to slow down, and be especially cognizant of drugs that available in extended release formulation. The diltiazem family drives me crazy! Cardizem, Taztia, Cartia XT......

When filling, I'm very meticulous. I get everything except the stock bottle and label out of my field of vision. That way I'm not distracted by another stock bottle, another vial, another label. It does help a lot. I'm a fast counter though, so I can keep up with the work flow. Once I'm done filling, the stock bottle goes immediately back to the shelf, or into a large bin with other stock bottles (if its busy).

During data entry, I refuse to use the "add to order" function when someone hands me multiple scripts. I know this saves a few seconds, but I would rather do each script individually and read each script. This slows me down and forces me to be more meticulous.

Mistakes in the pharmacy are going to happen. Look at it this way though, the vast majority of prescription drug mistakes are made by physicians, and you can be willing to bet that pharmacists catch at least half of these mistakes before they make it to the patient (I think this is being less than generous, we could possibly catch a great majority of them). A small fraction of prescription drug mistakes are made by pharmacists. Now imagine if you took pharmacists out of equation. Suddenly, all of the Rx mistakes made by physicians have no quality control procedure to protect the patient, and thus the amount of mistakes are extrapolated to a much larger figure than we have now. A world without pharmacists would be scary.

 

[DAW2]

grabbed a return to stock bottle off the shelf and used it according to what was on the label. patient called later and said pills didnt match what she had before. turns out previous rph had misfilled that bottle and it was the wrong pills in the bottle, but the labeled stuff was what i needed. didnt have a system that showed you a pill pic at the time. luckily she brought it back and didnt take any of it. phew.

 

[GreyFox2002]

grabbed a return to stock bottle off the shelf and used it according to what was on the label. patient called later and said pills didnt match what she had before. turns out previous rph had misfilled that bottle and it was the wrong pills in the bottle, but the labeled stuff was what i needed. didnt have a system that showed you a pill pic at the time. luckily she brought it back and didnt take any of it. phew.

Yikes. I always grab the original stock bottle along with the RTS bottle to compare tablets, just to be safe. Also, doesn't your labels show the tablet shape, color, and imprint for verification purposes?

 

[J ROD]

I check NDCs like a MF, lol!! I dont do much retail but as far as I know I have not given an error to a patient. I am relatively slow and take my time and use my checks. I have caught several dozen though.

I just dont get rushed and tell impatient customers do you want me to do it right, then let me take my time and get it right. Most calm down and realize I am looking out for them. The rest are why I hate retail,

I swear I am OCD on those bottles!! I look each Rx over several times and check all the pertinents.

 

[meister]

At my store we once filled a guy's tramadol as trazadone. He took it for a whole month. He wound up sleeping 10+ hours each day and had slurred speech. He's a nice guy but seriously I would have sued for that one.

It happened when we converted to a CVS store and reorganized our shelves to purely alphabetized rather than alphabetized by brand-name. So tramadol and trazadone wound up next to each other.

 

[meister]

By the way the worst medication errors are the ones you don't know about...

 

[DAW2]

ya there was no stock bottle as it was a 30 count stock bottle already tossed. and our archaic comp didnt have any pill id thingys. i should have went to clin pharm to check it out but didnt...bad me..

 

[Doctor M]

By the way the worst medication errors are the ones you don't know about...

Yeah, filling 500-600 daily with no overlap...i cant even imagine what went out sometimes...that is so scary...My first error was as a newly licensed pharmacist: I dispensed Navane (thiothixene) instead or Artane (trihexyphenidyl). My worst was sinemet 25/250 instead of atenolol/chlorthalodone 25/50. 2 months later I quit CVS. Im not saying that the volume caused it, but there were too many distractions! Tech asking me one trillion questions, phones, etc etc etc...

 

[lorain]

Yeah, filling 500-600 daily with no overlap...i cant even imagine what went out sometimes...that is so scary...My first error was as a newly licensed pharmacist: I dispensed Navane (thiothixene) instead or Artane (trihexyphenidyl). My worst was sinemet 25/250 instead of atenolol/chlorthalodone 25/50. 2 months later I quit CVS. Im not saying that the volume caused it, but there were too many distractions! Tech asking me one trillion questions, phones, etc etc etc...

this right here

im doing that volume, i just have one senior tech, the phones, etc...its a fact a mistake or 2 will be made....the ones i have made were minor, wrong strips given out, being my biggest

 

[RX8]

this right here

im doing that volume, i just have one senior tech, the phones, etc...its a fact a mistake or 2 will be made....the ones i have made were minor, wrong strips given out, being my biggest

What company?

 

[SoonerPharmD]

this right here

im doing that volume, i just have one senior tech, the phones, etc...its a fact a mistake or 2 will be made....the ones i have made were minor, wrong strips given out, being my biggest

i thought they gave you a low volume store? or have you not taken over yet?

i just saw a dumb mistake today whether it be the person calling it in or the rph not realizing a high dose for a 15 month old (or an adult as a matter of fact). since the tamiflu susp is on backorder we've been compounding it but it's 15mg/ml instead of 12mg/ml. anyway, he called to tell them we'd be compounding it and they said to give 8ml bid. the mom came back and said she thought that 8ml was a little high, i was like umm, yeah. she said she only gave 1/2 tea and i said to just give 2 ml and to we'd contact the MD to clarify.

the worst mistake i've made was giving metrogel-vaginal instead of metrogel. the lady came back later and said she was supposed to be using it for her face!! oops!

 

[Doctor M]

i thought they gave you a low volume store? or have you not taken over yet?

i just saw a dumb mistake today whether it be the person calling it in or the rph not realizing a high dose for a 15 month old (or an adult as a matter of fact). since the tamiflu susp is on backorder we've been compounding it but it's 15mg/ml instead of 12mg/ml. anyway, he called to tell them we'd be compounding it and they said to give 8ml bid. the mom came back and said she thought that 8ml was a little high, i was like umm, yeah. she said she only gave 1/2 tea and i said to just give 2 ml and to we'd contact the MD to clarify.

the worst mistake i've made was giving metrogel-vaginal instead of metrogel. the lady came back later and said she was supposed to be using it for her face!! oops!

That happens more often than you think! that really isnt that horrible at all...just a little uncomfortable when the pt comes back...

 

[Sparda29]

That happens more often than you think! that really isnt that horrible at all...just a little uncomfortable when the pt comes back...

That's why we separate the vaginal products from the other products. When its an ambiguous prescription, it is kinda awkward asking the patient where they are going to use it.

 

[Doctor M]

That's why we separate the vaginal products from the other products. When its an ambiguous prescription, it is kinda awkward asking the patient where they are going to use it.

Sometimes the doc may be ambiguous when he writes it, but that's when the rph should call to verify...but honestly, filling 500-600 daily, that's an easy one to get by...

 

[Thoughtfulsinner]

Some off the top of my head that have occurred in the past month:
Prozac 20mg instead of Prilosec 20mg (caught on refill)
Lamictal 100mg 2.5 tablets daily instead of Lamisil 250mg (caught on refill)
Symbyax given instead of Symbicort (patient caught same day)
Zithromax suspension 2ml day 1, 1 teaspoonful daily days 2-5 (patient caught when they ran out of liquid)
Famciclovir instead of famotidine (caught on refill)
Avelox instead of Avonex (patient caught same day)

But hey, it's hard to be perfect when you're doing 600 per day and giving out 50 flu shots daily.

 

[meister]

^^^^^ some of those are horrible......


It pays to be an educated patient.

 

[Sparda29]

Sometimes the doc may be ambiguous when he writes it, but that's when the rph should call to verify...but honestly, filling 500-600 daily, that's an easy one to get by...

I know, I've seen that before. I got an ambiguous script at 9PM on a Sunday night just like that. The patient was some 20 year old chick and I was trying to keep a straight face when I asked her if she was supposed to use it vaginally or facially.

 

[Quiksilver]

you catch errors in hospital too... a pharmacist ran an rx for busulfan and was going to give pure busulfan without a dilution.



I made an error once in community that reached the patient. Gave them klonopin 2 mg instead of the 1 mg that they were supposed to get

 

[lorain]

What company?

wags

 

[lorain]

i thought they gave you a low volume store? or have you not taken over yet?

i just saw a dumb mistake today whether it be the person calling it in or the rph not realizing a high dose for a 15 month old (or an adult as a matter of fact). since the tamiflu susp is on backorder we've been compounding it but it's 15mg/ml instead of 12mg/ml. anyway, he called to tell them we'd be compounding it and they said to give 8ml bid. the mom came back and said she thought that 8ml was a little high, i was like umm, yeah. she said she only gave 1/2 tea and i said to just give 2 ml and to we'd contact the MD to clarify.

the worst mistake i've made was giving metrogel-vaginal instead of metrogel. the lady came back later and said she was supposed to be using it for her face!! oops!

Im getting cold feet on the slow store manager spot, i realise i dont really like the district supervisor and want to talk to him as little as possible...the offer is there, im just not sure at the moment and im evaluating the position at the moment

 

[lorain]

Sometimes the doc may be ambiguous when he writes it, but that's when the rph should call to verify...but honestly, filling 500-600 daily, that's an easy one to get by...

again this.....ive seen that metrogel before a couple times, its really awkard, but not a big deal

there are so many small ones that i let go or else the volume would eat me alive

 

[lorain]

Some off the top of my head that have occurred in the past month:
Prozac 20mg instead of Prilosec 20mg (caught on refill)
Lamictal 100mg 2.5 tablets daily instead of Lamisil 250mg (caught on refill)
Symbyax given instead of Symbicort (patient caught same day)
Zithromax suspension 2ml day 1, 1 teaspoonful daily days 2-5 (patient caught when they ran out of liquid)
Famciclovir instead of famotidine (caught on refill)
Avelox instead of Avonex (patient caught same day)

But hey, it's hard to be perfect when you're doing 600 per day and giving out 50 flu shots daily.

ive seen a lot of zithromax mistakes, but most due to writing

 

[VCU2011]

I will never forget my first mistake. It was my first year as a tech (6 years ago), but I was already wanting to attend rx school so had been getting to know the drugs pretty well. I was at the entering window and pt dropped off a script for what I entered as Coumadin 10mg qd. It was filled as such, but when i got to the verification station I heard the pharmacists discussing it. It turns out that the physician had wrote Coumadin 1.0 mg qd, but the decimel was just a darker spot on the bottom of the 0. Called to verify if it was 10 or 1 and they verified it as 1.

Granted that was a HORRIBLE way for the physician to write that script, but I still felt awful and will never forget that one. thank god it didn't get out...

 

[npage148]

I will never forget my first mistake. It was my first year as a tech (6 years ago), but I was already wanting to attend rx school so had been getting to know the drugs pretty well. I was at the entering window and pt dropped off a script for what I entered as Coumadin 10mg qd. It was filled as such, but when i got to the verification station I heard the pharmacists discussing it. It turns out that the physician had wrote Coumadin 1.0 mg qd, but the decimel was just a darker spot on the bottom of the 0. Called to verify if it was 10 or 1 and they verified it as 1.

Granted that was a HORRIBLE way for the physician to write that script, but I still felt awful and will never forget that one. thank god it didn't get out...

That is the doctors fault for putting in the trailing zero's. It's even on that list of things banned by jcaho

 

[MinnieRx]

How do you handle such situations when a patient comes back with the wrong medication?

 

[meister]

Apologize, give them a refund, don't charge them anything, notify MD if it is a significant error, kiss their ass and pray they don't report you to the board.

 

[Sparda29]

Caught this potential error in a 5 year old. Doctor wrote a prescription for:

Zithromax 200 mg/5 ml
No Quantity Indicated
5 year old patient
4 1/2 Teaspoons on Day 1
2 1/4 Teaspoons Day 2-5

Called up the doctor's office, turns out that the doctor told the secretary to write the script for him, and the secretary ****ed up.

 

[spacecowgirl]

How do you handle such situations when a patient comes back with the wrong medication?

don't get defensive, ever. Just be apologetic.

The only error I know got to a patient was when I filled two scripts - one for Robaxin and one for ibu. For reasons I still cannot figure out, I filled both bottles with ibu (both large white ovals caplets). The patient called and he wanted me to come to his house with the right med I felt really bad but he was one creepy dude and would not be satisfied with anything short of me bringing it to him. I didn't BTW, I don't know what finally happened.

I'm sure I make a lot that are never caught. That's just how it is, sadly. I do my very best, double-check everything and have liability insurance.

 

[eeyore spice]

Worst one I ever saw was in a hospital: large amount (I forget the exact dose) of hydralazine instead of hydrocortisone.

Patient survived, but I think she needed a shock.

To add to the horror, the pharmacist showed me the order and asked if it wasn't difficult to read and could have easily been mistaken for hydralazine.

I looked at the order, swallowed hard and said "...uh...yeah...that is pretty hard to read..."

It wasn't.

 

[lorain]

pt got mucinex DM, went to refill it today, only to learn the rx was for regular mucinex max strenght...some1 just picked the DM and manually overrode the scanner

Pt wasnt mad at all b/c the D really helped her, but still

 

[Sparda29]

pt got mucinex DM, went to refill it today, only to learn the rx was for regular mucinex max strenght...some1 just picked the DM and manually overrode the scanner

Pt wasnt mad at all b/c the D really helped her, but still

Mucinex by itself is a pretty crappy drug.

 

[DrugDealer]

Apologize, give them a refund, don't charge them anything, notify MD if it is a significant error, kiss their ass and pray they don't report you to the board.

Exactly! And don't try to make excuses as to why you made the mistake. Just say "my mistake, I'm so sorry"

 

[lorain]

md ok with mucinex d...hooray end of problem

 

[Farmercyst]

Pt got wrong qty of Neurontin Elxr because tech Neurontin 300mg (15mL) however many times/day for 30 days. Rx was for 600 mg dose. The Pharmacist caught the dose error, but forgot to recalculate the final volume. So patient called in after 2 weeks with no meds wondering why she ran out.

 

[njac]

Speaking of a sentinel event we've just had...

Has anyone ever seen insulin (specifically Lantus) ordered in 0.5 unit increments?

 

[njac]

And on the liability insurance front, I was advised recently not to carry it because it increases your chances of getting sued because they can actually get something from you?

That was the first I'd heart of that.

 

[Pharmavixen]

And on the liability insurance front, I was advised recently not to carry it because it increases your chances of getting sued because they can actually get something from you?

That was the first I'd heart of that.

How would the pts know you have liability insurance?

(I carry 2M worth - don't tell my pts.)

 

[eightball]

Speaking of a sentinel event we've just had...

Has anyone ever seen insulin (specifically Lantus) ordered in 0.5 unit increments?

No..no but out of curiosity, how did that result in a sentinel event. Lantus is long acting and has wide therapeutic index.

What could have gone wrong there/

 

[njac]

No..no but out of curiosity, how did that result in a sentinel event. Lantus is long acting and has wide therapeutic index.

What could have gone wrong there/

5.5 units was entered as 55. And given 3 days in a row.

 

[Old Timer]

And on the liability insurance front, I was advised recently not to carry it because it increases your chances of getting sued because they can actually get something from you?

That was the first I'd heart of that.

It depends on who you work for. The policies are sooooo cheap because they are secondary to your employers insurance. You have to exhaust your employers insurance before your insurance company will pay a penny. If you work for CVS or Walgreens that is not going to happen. If it does, your little policy won't matter either.

If you are a resident or a hospital pharmacist where the chances of error causing harm are greater than in a community practice, I would carry it.

 

[njac]

How would the pts know you have liability insurance?

(I carry 2M worth - don't tell my pts.)

I think it's more that if the lawyers find out your carry it they're more likely to keep you on the suit.

 

[spacecowgirl]

Has anyone ever seen insulin (specifically Lantus) ordered in 0.5 unit increments?

No. That's just stupid. How do you even measure 0.5 unit of insulin with any sort of precision that would make it worthwhile?

I do love CPOE (which we then verify).

 

[ancienbon]

i floated at a store a few days where a prescription for prednisolone 15mg/5 written for a 5 month old child was filled incorrectly. Script was written for 1 teaspoon on day 1, then 1/2 teaspoon daily for 3 days. upon checking the computer , I saw script was verified correctly but the label on the bottle that the mom got said 2.5 teaspoons daily . The mom gave the child that high dose for 3 days. when she realized the mistake, she took the infant to the er. They said everything is fine with the child
,
I am not sure how this mistake happened. it seems that the verifying pharmacist may have caught the error, and updated the script, but forgot to put the new label on the bottle.

 

[PharmNerdMatt]

Sounds like you know how it happened. Someone started to type 2.5 mL, accidentally typed 2.5 tsp, it was fixed, then when re-verified the pharmacist only checked the entered Sig against the Rx, not the actual label.

 

[trailerpark]

I like how Walmart makes you scan the bottle and it wont even print the label until the right bottle is scanned so if you 4 point the rx correctly and the tech actually uses what they scan, errors are reduced by a lot.

 

[Leper Messiah]

I answered a call yesterday from the mother of a pediatric patient who was given generic augmentin despite the fact that the profile clearly listed an amoxicillin allergy. Fortunately, she didn't administer the drug.

Also yesterday, a patient opened her bag of metformin 500 (2 bottles) and found another patient's bottle of metformin 1000. They didn't even have similar names. A tech probably grabbed all three off of the ScriptPro and put them in the basket, but still... fast food pharmacy is scary.

Edit: I guess it was metformin since there is no 1000mg gabapantin

 

[EML9255]

Recently I learned I dispensed metformin er 500 (osm) instead of metformin er 500

The patient took for a month and then we faxed the md for refills and he faxed back osm but then the Rph filling checked his history and saw he had always gotten metformim er 500

 

[Carboxide]

I answered a call yesterday from the mother of a pediatric patient who was given generic augmentin despite the fact that the profile clearly listed an amoxicillin allergy. Fortunately, she didn't administer the drug.

Also yesterday, a patient opened her bag of gabapentin 600 (2 bottles) and found another patient's bottle of gabapentin 1000. They didn't even have similar names. A tech probably grabbed all three off of the ScriptPro and put them in the basket, but still... fast food pharmacy is scary.

What was the allergy, though? A lot of times it's "nausea/vomiting" or "diarrhea" which is not an allergy. I would easily override that and dispense.