Common Hospital Medication Errors

[baronzb]

Let's create a list and cause for the most common medication errors, whether it is from bad COE from non-pharmacy staff, duplications, clinical issues inducing odd therapy, etc.

How about common hospital drug medication errors? I will start the list, please add to it:

KCL
bridging (the whole gauntlet)
albumin

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[DOOM N GLOOM]

Let's create a list and cause for the most common medication errors, whether it is from bad COE from non-pharmacy staff, duplications, clinical issues inducing odd therapy, etc.

How about common hospital drug medication errors? I will start the list, please add to it:

KCL
bridging (the whole gauntlet)
albumin

A common avoidable medication error is hiring a hospital pharmacist who went to a pharmacy school outside the top 50 (and that’s being generous). It’s like winding up a ticking time bomb and setting it next to your bed.

 

[AlwaysContrary]

I've noticed like every single ER doc confused the dosing between macrodantin and macrbid

had a nurse do a med rec and wrote Keppra 100 mg BID

I don't even wanna talk about the med recs for warfarin. Maybe it was my institution, but it seemed like nurses had no idea the severity of getting something like that wrong.

Depending on the provider, antibiotics can be a real mess. Had a new FM MD covering the ward (rural hospital btw) had a patient on like 6 antibiotics with double and triple coverage

Not dosing to renal function and/or liver function. Thankfully a lot of the MDs will just write pharmacy to dose if they don't know

that's some stuff just off the top of my head.

 

[ornithoptor]

This is a well intended proposal. Not sure if you work in hospital or not. There is some resources available so you don't have to reinvent the wheels.

There is a organization called ISMP, who collect, compile and analyze all of the adverse events. Then bring out best practice and solutions and offer monthly news letters.

Please take a look at the Home . It is a great resource, especially for process changes.

 

[jjcayce123]

nothing pisses me off more than non-formulary orders for things that are on the formulary. It bypasses allergies and is just a sign of a crap hospitalist

 

[BidingMyTime]

Transcribing errors on pt's home meds that aren't in the system, esp with frequencies (stuff being put in as daily when it should be every other day or even weekly) or home meds showing as active in the system when the pt no longer takes them.

 

[sakigt]

nothing pisses me off more than non-formulary orders for things that are on the formulary. It bypasses allergies and is just a sign of a crap hospitalist

It may be your computer system. Ours pushes through Toprol XL as tartrate because we don't have Toprol XL 100mg tabs. Fun times.

 

[TimeZero]

Off the top of my head:

1. Sending PO levofloxacin for PO levetiracetem and vice versa.
2. Sending the wrong PO Depakote formulation.
3. Stimulant conversion for pysch patients.
4. Nursing heparin calculation errors in the ED.
5. Antibiotic misuse and refusal to de-escalate.
6. Diagnosing every patient with a questionable chest Xray with pneumonia.
7. Poorly done medication histories.
8. Resistance to organizational approved clinical initiatives.

Agreed with keeping up with the ISMP newsletters, there's a reason sterile water liter bags aren't stocked outside of the pharmacy.

 

[jjcayce123]

Poorly done medication histories.

This is a big one. Especially if there is not an ED pharmacist doing the initial med rec.

 

[CYP3A4]

My personal pet peeve is the confusion between various IV electrolyte formulations. Rates are always screwed up. The incorrect salt is always ordered. Overdoses. Underdoses. Etc. I feel like neither the prescribers nor the pharmacists know what they are doing. I shake my head every time I have to fix someone's Kphos order to be run over 30 minutes along with KCL 40meq undiluted in the same peripheral line.

 

[BidingMyTime]

My personal pet peeve is the confusion between various IV electrolyte formulations. Rates are always screwed up. The incorrect salt is always ordered. Overdoses. Underdoses. Etc. I feel like neither the prescribers nor the pharmacists know what they are doing. I shake my head every time I have to fix someone's Kphos order to be run over 30 minutes along with KCL 40meq undiluted in the same peripheral line.

There should be some rudimentary teaching on this. At least when I was in school, IV's solutions were not ever mentioned. Everything I learned about them was on-the-job. I imagine it's the same at medical school.

 

[jjcayce123]

Orders for IV hydralazine on a general med unit..no telemetry

 

[BC_89]

Had to write an MFR recently due to some of our rotations of pharmacists (inpatient to outpatient in the hospital) misplacing ordered meds that pharmaceutical companies can’t mark better with distinguishable colors from their counterparts.

Same thing happened with mis-calculated Baxter IV bags that the senior tech can’t possibly go wrong on (she’ll be missed).

 

[CYP3A4]

There should be some rudimentary teaching on this. At least when I was in school, IV's solutions were not ever mentioned. Everything I learned about them was on-the-job. I imagine it's the same at medical school.

I agree. I was lucky to do an intense critical rotation and my preceptor really harped on lytes and fluids. In school we had a few lectures in therapeutics but it didn't make sense at the time.

 

[BidingMyTime]

View attachment 243203 Same thing happened with mis-calculated Baxter IV bags that the senior tech can’t possibly go wrong on (she’ll be missed).

You fired a technician for making a calculation error? There must be more to this story.

 

[BC_89]

You fired a technician for making a calculation error? There must be more to this story.

Oh no. I’m in no position to terminate anyone..

The hospital is on a military base and as per regulation by our command if a medication error occurs it’s the responsibility of active duty personnel to write up a Memo detailing the events and specifics. As the individuals involved send out the patient safety report, I also have to discuss, sign, and send out my memo of events within 24-48 hours.

As for the senior tech much more to the story as well. Swapped narcotics over a duration of time and came to work drunk after involvement in a hit and run. She had a reputation of precision and accuracy and very good at her job. All I know is she gone and a replacement was made.

 

[BidingMyTime]

As for the senior tech much more to the story as well. Swapped narcotics over a duration of time and came to work drunk after involvement in a hit and run. She had a reputation of precision and accuracy and very good at her job. All I know is she gone and a replacement was made.

Oh that makes much more sense!

 

[farmadiazepine]

I can't stand when providers order non-formulary medications. We have a formulary for a reason, yet our non-formulary section keeps getting bigger and bigger by the day..

I also can't stand providers ordering "patient's own medications" while they are in the hospital. It's absolutely stupid.

 

[sakigt]

I can't stand when providers order non-formulary medications. We have a formulary for a reason, yet our non-formulary section keeps getting bigger and bigger by the day..

I also can't stand providers ordering "patient's own medications" while they are in the hospital. It's absolutely stupid.

The non formulary med orders that get pushed through: except its stupid OTC stuff.

"Sir with an MI can your family member bring in your Horney Goat Weed?"

 

[Rouelle]

The non formulary med orders that get pushed through: except its stupid OTC stuff.

"Sir with an MI can your family member bring in your Horney Goat Weed?"

Might as well go ahead and add the common essential oils to the formulary, too.

 

[Sparda29]

There should be some rudimentary teaching on this. At least when I was in school, IV's solutions were not ever mentioned. Everything I learned about them was on-the-job. I imagine it's the same at medical school.

Concur. Prior to my hospital getting EPIC, the IV solutions weren't even considered meds that MDs had to write an order to pharmacy for unless it had potassium in it.