Always call to clarify

[spacecowgirl]

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http://www.kare11.com/news/news_article.aspx?storyid=944278

Excerpt:

The state investigation found Bethany medical workers misread the prescription, and for a week Darlene received 10 times the amount of potassium chloride that the doctor prescribed - 80 millequivalents instead of 8. Three employees misinterpreted the handwritten order according to the state. Even the pharmacist who filled the order thought the dose was unusually high.

 

[Pharmacy Kid]

That's why you don't scribble. You cross out using one line and initial next to it.

 

[lorain]

u cross out, u write error, u initial

but that imo is the fault of the rph, 80 is a bit high, and you should always call if you arent sure

 

[Carboxide]

If the pharmacist was unclear, he should have called. But if that dose is high but still seen, then it happens. If THREE people misinterpreted the Rx, and the pharmacist noted it was high (meaning he probably spent extra time scrutinizing the prescription), then it's the doctor's fault.

 

[Old Timer]

Even the doctor who wrote the order told state investigators he has never prescribed 80 millequivalents of potassium. He says he first wrote down the number 16, then crossed it out and wrote 8 because he knew the smaller tablets would be easier for Darlene to swallow.

The doctor is a ***** who should shut up soon before he gets in on the lawsuit bandwagon. There have never been 16 meq tablets. In fact, 8 meq tablets are wax matrix and probably should not have been used in geriatric patients anyway.

That being said, the pharmacist should have checked the dose, 80 meq is very high....

 

[spacecowgirl]

I have never seen a dose of 80 meq. Daily? At once? No way.

Everyone is at fault here. Everyone who for even a second said "Hmmm, that's odd" is at fault.

Taken an extra five minutes. Annoy a doctor, who cares? If you're acting in the best interest of the patient, you are ALWAYS right.

 

[confettiflyer]

yeah never seen 16...i've seen 80 meq dispensed ONCE, and even that was inpatient shot into a liter bag and the pharmacists called upstairs to verify. Even I verified it with the pharmacist before making it.

though i wonder if the physician is one of those a-holes that wrote "DO NOT CALL/DO NOT PAGE" and the end of every order.

the big "duh" moment for me is the fact that an 8 meq tablet exists and 80 meq is highly unusual.

 

[Carboxide]

I have never seen a dose of 80 meq. Daily? At once? No way.

Everyone is at fault here. Everyone who for even a second said "Hmmm, that's odd" is at fault.

Taken an extra five minutes. Annoy a doctor, who cares? If you're acting in the best interest of the patient, you are ALWAYS right.

Now, that's the kicker. If it's never been seen before, then it's definitely ALWAYS a "call to verify" even if the script is typed and as clear as day. Heck, we've had docs send down Rxs with the wrong NAME on them.

 

[iFarm]

80meq potassium in a TPN is not that rare. However this was PO.

Maybe the nurses at the nursing home figured that since the TPN patient down the hall is on 80meq... it was a reasonable dose for this patient too? 😱

I can't believe any pharmacist would dispense 80meq in that situation without questioning it. It doesn't matter if it's not crossed out properly, you still have to question it. 🙁

 

[npage148]

I have never seen a dose of 80 meq. Daily?

I have, the doctor was insistent because he couldn't get her levels up. We figured that she wasn't taking her pills, becasue the customer was a bit of a pain in general.

But if you're letting 80meq K+ get past you without ample follow-up and documentation you deserve to have your license pulled

 

[Dalteparin]

I have never seen a dose of 80 meq. Daily? At once? No way.

Everyone is at fault here. Everyone who for even a second said "Hmmm, that's odd" is at fault.

Taken an extra five minutes. Annoy a doctor, who cares? If you're acting in the best interest of the patient, you are ALWAYS right.

QFT. This is a classic example of the "swiss cheese" phenomenon.

 

[OUTexan]

From what I read on this, it doesn't come out and say that the pharmacist contacted the physician. However, with the way the article was blaming the nurses, it seemed like the pharmacist possibly called the nurse and the nurse gave the OK without talking to the doctor. I think that is why the blame is on the nurse and not the pharmacist for this one. I would bet the pharmacist wrote down that the nurse said it was okay. But that is just the way I think it went down.

I know when I try to call a physician, usually the receptionist tries to clarify for me. I then ask if I can at least talk to the nurse. I don't know how many nurses just clarify things without bothering to ask the doctors, but I know it does happen. One time we had a doctor write for cipro and levaquin. We called to verify that he wanted both and the nurse said yes. The doctor called back a couple days later irrate that both were dispensed. We politely informed him that nurse so and so ok'ed it. He then said, next time ask to talk to him. Yea, like it is that easy to talk to a doctor.