Medication Error: Who's fault is it?

[Sparda29]

Patient comes into the ER for whatever reason and is found to be hypertensive. Patient is allergic to ACE-inhibitors. The ER physician assistant orders enalaprilat. Due to the allergy, the PA receives a hard-stop on entering the order and types in "ok" to bypass the hard-stop.

Pharmacist goes to verify order and an allergy alert pops up. Pharmacist looks into it, notices that the allergic reaction to the ACE-inhibitors according the computer is anaphylaxis. Reading further into it, pharmacist sees that the PA signed off on the allergic reaction and typed in "ok". Pharmacist took this as the prescriber being aware of the allergy and signed off on it too.

Nurse gets the med, administers it without checking the allergy wristband and the patient immediately has a reaction and BP drops to 50/25, rapid response called and was fluid resuscitated later on.

IMO it is mainly the prescribers fault.

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[BeLikeBueller]

Patient comes into the ER for whatever reason and is found to be hypertensive. Patient is allergic to ACE-inhibitors. The ER physician assistant orders enalaprilat. Due to the allergy, the PA receives a hard-stop on entering the order and types in "ok" to bypass the hard-stop.

Pharmacist goes to verify order and an allergy alert pops up. Pharmacist looks into it, notices that the allergic reaction to the ACE-inhibitors according the computer is anaphylaxis. Reading further into it, pharmacist sees that the PA signed off on the allergic reaction and typed in "ok". Pharmacist took this as the prescriber being aware of the allergy and signed off on it too.

Nurse gets the med, administers it without checking the allergy wristband and the patient immediately has a reaction and BP drops to 50/25, rapid response called and was fluid resuscitated later on.

IMO it is mainly the prescribers fault.

As much as I hate to say it, this sounds like the perfect case for a fishbone diagram. Sounds like there were multiple system failures.

 

[Sparda29]

As much as I hate to say it, this sounds like the perfect case for a fishbone diagram. Sounds like there were multiple system failures.

Do you think the pharmacist should have called the PA and asked if they really wanted this drug even though they had already signed off "ok"?

 

[Sparda29]

DUPLICATE

 

[OmiPharmD]

Yes. I still call when they override something that looks like a bad idea. I also call the RN to make sure they don't give it in the meantime.

Sent from my GT-N8013 using Tapatalk

 

[BeLikeBueller]

Do you think the pharmacist should have called the PA and asked if they really wanted this drug even though they had already signed off "ok"?

Well, I mean I'm a student...so I don't have the whole "what goes on in the real world" perspective just yet, but personally I would have liked a little more information on the hard-stop response than just "ok."

Still, like you stated, it does sound like an acknowledgement by the PA that they understood the allergy. So should the pharmacist be hung out to dry on this one? Nah, definitely not.

I think this error would have to be looked at from a system-failure perspective. Did the PA just have alert fatigue? Did the PA think pharmacy would intervene if this were an issue? Did the pharmacist think the PA understood the implications of the allergy? Did the nurse fail to follow protocols?

Rather than saying that it was solely the PA's fault (although the error obviously started with the PA), I think the bigger question is how can you fix your protocols, ordering process, and administration protocols so that this kind of thing is caught next time.

 

[Sparda29]

Any time you order something that the patient is potentially allergic to or the computer thinks that there will be a therapy duplication, the system will pop-up a message to the person entering the order. You will not be allowed to proceed with the order unless you click the icon that you acknowledge the message that the computer is giving you. After you acknowledge it, the choices available to check off are things like : provider aware/approved, pharmacist aware/approved, to be discussed w/ primary care, n/a.

Too many times, I see the doctors just clicking through the hard stops so they can enter the order and leave. The policy should be changed to providers having to enter a full explanation when over-riding an allergy alert or therapy duplication alert, rather than just clicking through.

 

[MackandBlues]

I think all three are at fault but hopefully yours is not a punitative system and they are system errors, except the RN that didnt check the allergy wristband, now that's just crazy. Provider for just clicking through the hard stop on the allergy, pharmacist for verifying order when patient has anaphylaxis (!!!!!) because that definetly needs clarification, then the RN who didn't ask the patient about allergies/check the wristband.

 

[awval999]

If the allergy really read: anaphylaxis...

1. I'm checking medication history to see if patient had gotten an ACE before
2. If no... I'm calling every time.

We use EPIC and have I-vents to document pharmacy communications.

 

[PharMed2016]

I think all three are at fault but hopefully yours is not a punitative system and they are system errors, except the RN that didnt check the allergy wristband, now that's just crazy. Provider for just clicking through the hard stop on the allergy, pharmacist for verifying order when patient has anaphylaxis (!!!!!) because that definetly needs clarification, then the RN who didn't ask the patient about allergies/check the wristband.

I'm assuming that the patient has been to said ED before or that the nurses did the intake. Physician glances at profile and tells PA to put in said order... PA assumes that the physician is aware of everything including interaction... bypasses without looking at interaction... pharmacist assumes physician/PA understood interaction... rx gets okay-ed... nurse assumes everything is alright given that the physician/PA ordered it, the pharmacist approved it... gives to patient. Unfortunately everyone made assumptions. Multiple system failure... can anyone say QA?

 

[DrWrong]

Patient comes into the ER for whatever reason and is found to be hypertensive. Patient is allergic to ACE-inhibitors. The ER physician assistant orders enalaprilat. Due to the allergy, the PA receives a hard-stop on entering the order and types in "ok" to bypass the hard-stop.

Pharmacist goes to verify order and an allergy alert pops up. Pharmacist looks into it, notices that the allergic reaction to the ACE-inhibitors according the computer is anaphylaxis. Reading further into it, pharmacist sees that the PA signed off on the allergic reaction and typed in "ok". Pharmacist took this as the prescriber being aware of the allergy and signed off on it too.

Nurse gets the med, administers it without checking the allergy wristband and the patient immediately has a reaction and BP drops to 50/25, rapid response called and was fluid resuscitated later on.

IMO it is mainly the prescribers fault.

I would have never verified enalaprilat in the first place. It's a terrible drug for hypertensive emergency. But, given any other situation, as Awva said above, I would check the pts med history and then walk over and talk to the PA (we also use EPIC).

To answer your question, it's everyone's fault.

 

[MackandBlues]

I'm assuming that the patient has been to said ED before or that the nurses did the intake. Physician glances at profile and tells PA to put in said order... PA assumes that the physician is aware of everything including interaction... bypasses without looking at interaction... pharmacist assumes physician/PA understood interaction... rx gets okay-ed... nurse assumes everything is alright given that the physician/PA ordered it, the pharmacist approved it... gives to patient. Unfortunately everyone made assumptions. Multiple system failure... can anyone say QA?

But the big problem I see is that this all the "assuming" could have been caught if the RN had actually checked the patient's arm band...

 

[Sparda29]

Another issue I found out today about the ER in our hospital which I had no idea about. I honestly thought that the doctors and nurses wait for us to verify the order before administering it.... nope. Most of the time the order has already been administered to the patient by the time the doctor enters it into the EMR and we verify it. What's the purpose of me verifying the ****ing order if you already gave it?

 

[MackandBlues]

Another issue I found out today about the ER in our hospital which I had no idea about. I honestly thought that the doctors and nurses wait for us to verify the order before administering it.... nope. Most of the time the order has already been administered to the patient by the time the doctor enters it into the EMR and we verify it. What's the purpose of me verifying the ******* order if you already gave it?

yea our hospital ER is like that too and we have Epic

 

[npage148]

At least you fixed his hypertension?!

 

[PharMed2016]

But the big problem I see is that this all the "assuming" could have been caught if the RN had actually checked the patient's arm band...

You know what they say about assuming... it makes an ASS out of U and ME.

 

[confettiflyer]

Yeah ED is outpatient and review is retrospective at every institution I've been to.

It's prescriber error first and foremost, they affirmed the warning whether they actually read it or not.

Contributing: unwilling of the pharmacist to challenge, alert fatigue.

I personally would have called, I'm pretty cavalier about approving orders despite a listed allergy, but anaphylaxis? I always always talk to the prescriber if that's listed...especially where it makes sense, like PCN or ACEI.

The only time I wouldn't is if there was a detailed "okay" free text sentence typed by the prescriber and not just via the CPOE system override reason drop down...or if pt got it before.

 

[pharmerjohn]

Any time you order something that the patient is potentially allergic to or the computer thinks that there will be a therapy duplication, the system will pop-up a message to the person entering the order. You will not be allowed to proceed with the order unless you click the icon that you acknowledge the message that the computer is giving you. After you acknowledge it, the choices available to check off are things like : provider aware/approved, pharmacist aware/approved, to be discussed w/ primary care, n/a.

Too many times, I see the doctors just clicking through the hard stops so they can enter the order and leave. The policy should be changed to providers having to enter a full explanation when over-riding an allergy alert or therapy duplication alert, rather than just clicking through.

Speaking of policy, does anyone know if any hospital uses Lean or Six Sigma to help mitigate errors by implementing a policy and procedure for the ordering and administering of meds?

 

[Sparda29]

Yeah ED is outpatient and review is retrospective at every institution I've been to.

It's prescriber error first and foremost, they affirmed the warning whether they actually read it or not.

Contributing: unwilling of the pharmacist to challenge, alert fatigue.

I personally would have called, I'm pretty cavalier about approving orders despite a listed allergy, but anaphylaxis? I always always talk to the prescriber if that's listed...especially where it makes sense, like PCN or ACEI.

The only time I wouldn't is if there was a detailed "okay" free text sentence typed by the prescriber and not just via the CPOE system override reason drop down...or if pt got it before.

Prescriber had picked the drop down reason and typed in "ok" into the freetext field.

 

[farmadiazepine]

This is why prescribers should not be given the authority to override DURs and allergy information in the computer system. This is the job of the pharmacist. If the prescribers wrote down for IV enalapril and then the next check was the RPh, there would have been a stop and the RPh would not dispense and question the prescriber.

Bad on the part of the PA who overrode it. PA's go to school for such little time and have very little knowledge about drugs and pharmacology and all that ish. Ask them to name members of the ACE-inhibitor class and I'm sure they won't know or will have a tough time doing it.

But also bad on part of the RPh. WHY wouldn't you go back and question it? Anaphylaxis alert comes up in the computer and your first job is to NOT DISPENSE.

Yea its an error by a doctor, but PA should of caught it, if not, then RPh should have caught it.

I can't blame the nurse on this. The person who gets paid the least money should not be at fault at all, especially after going thru checks by a doctor, PA, and RPh.

 

[WVUPharm2007]

A PA prescribing enalaprilat is enough by itself to warrant extra scrutiny. Was the dose right at least? I've seen that get messed up so many times its frightening. "20mg IV q4-6 if SBP>160." Ummm...no. Then they'll say, "but that's what they take PO."

Guh.

 

[TLAD123]

IMO it is mainly the prescribers fault.

There is no "mainly"... it's anyone's fault for recognizing the problem and not stepping up to advocate for the patient. Instead, everyone assumed, and look what happened. Legally, ethically, medically it was everyone's fault. I would take more responsibility as a pharmacist - we have the MOST drug knowledge in the medical field - maybe the PA did not know enalaprilat was/is an ACEi and just wanted to get the med ASAP. WE are the ones who need to stop a med error in its tracks.

But as with any error, the system needs to be evaulated. Maybe the alert wasn't evident enough to make an impact on the PA's decision. Evaulate the system, don't blame the med professionals. Take responsibility for fixing the problem before it happens...

 

[lcucgrace]

Physician glances at profile and tells PA to put in said order... PA assumes that the physician is aware of everything including interaction... bypasses without looking at interaction... pharmacist assumes physician/PA understood interaction... rx gets okay-ed... nurse assumes everything is alright given that the physician/PA ordered it, the pharmacist approved it.

 

[Sparda29]

A PA prescribing enalaprilat is enough by itself to warrant extra scrutiny. Was the dose right at least? I've seen that get messed up so many times its frightening. "20mg IV q4-6 if SBP>160." Ummm...no. Then they'll say, "but that's what they take PO."

Guh.

The dose was correct, Enalaprilat 1.25 mg IVpush one time dose. In retrospect, why not give a Labetolol IV push or a Hydralazine IV push?

 

[BidingMyTime]

Patient comes into the ER for whatever reason and is found to be hypertensive. Patient is allergic to ACE-inhibitors. The ER physician assistant orders enalaprilat. Due to the allergy, the PA receives a hard-stop on entering the order and types in "ok" to bypass the hard-stop..
IMO it is mainly the prescribers fault.

Well, the final responsibility for it goes to the PA, so one could say that (s)he is ultimately responsible for it....but ultimately, its everyones fault who didn't follow through on their responsibilities. I can understand the ease of overriding, 90% of the time when people say they are allergic to something, they mean they had a side-effect that they didn't like from the medicine. And when talking about a huge class like ACE-I's, a true allergic reaction was probably to a specific agent, and not to every drug in the class. Still, it is the RPH's, and the RN's responsibility to make sure one of the above is true before giving the medication. The RPH is the one who is in the best position & best educated, to question the allergy, before approving it for administration (the nurse might not have realized that enalaprilit is an ACE-I, even if she did check the allergy band). ESPECIALLY when the RPH knows that Drs & PA's are routinely signing off on allergies & DUR's without really looking at them.

And, as others have mentioned, the usualness of ordering IV enalaprilit itself is reason to double question the order.

 

[Chemistjoey]

Physician glances at profile and tells PA to put in said order... PA assumes that the physician is aware of everything including interaction... bypasses without looking at interaction... pharmacist assumes physician/PA understood interaction... rx gets okay-ed... nurse assumes everything is alright given that the physician/PA ordered it, the pharmacist approved it.

Even if this was okay'ed and understood by the Physician/PA isn't it a pharmacist's job to step up and not allow this medication to be dispensed regardless of what the physician thinks? One of several reasons i choose this profession is because of the autonomy i thought pharmacists had. According to the replies in this thread it seems we are at the mercy of the physicians and we follow exactly what they say regardless of our thoughts. Is this the case? please shed some light on this issue. If all we do is act like robots and dispense what were told it doesn't seem like we are an integral part of the hospital healthcare team.

 

[TLAD123]

Even if this was okay'ed and understood by the Physician/PA isn't it a pharmacist's job to step up and not allow this medication to be dispensed regardless of what the physician thinks? One of several reasons i choose this profession is because of the autonomy i thought pharmacists had. According to the replies in this thread it seems we are at the mercy of the physicians and we follow exactly what they say regardless of our thoughts. Is this the case? please shed some light on this issue. If all we do is act like robots and dispense what were told it doesn't seem like we are an integral part of the hospital healthcare team.

+1

I'm saddened by the pharmacists here trying to blame a physician for not having the special drug knowledge that we so boastfully claim to have. How can we advance our profession if we don't take responsibility for questioning a medication error when we see it in its tracks?

It's like a bartender and a drunk (please excuse the analogy, it's the first thing that came into my head). Think: a bartender is holding someone's keys for them to ensure they don't kill themselves or anyone else trying to drive after they get drunk. If the bartender gives the keys to the drunk after they've asked for them, even if the bartender knows he shouldn't (but hey, the person asked so it must be okay) and the drunk drives, crashes and kills himself, who's at fault? The person for getting drunk in the first place, or the bartender for giving up the keys?

 

[Sparda29]

Even if this was okay'ed and understood by the Physician/PA isn't it a pharmacist's job to step up and not allow this medication to be dispensed regardless of what the physician thinks? One of several reasons i choose this profession is because of the autonomy i thought pharmacists had. According to the replies in this thread it seems we are at the mercy of the physicians and we follow exactly what they say regardless of our thoughts. Is this the case? please shed some light on this issue. If all we do is act like robots and dispense what were told it doesn't seem like we are an integral part of the hospital healthcare team.

No. If the physician acknowledges the fact that the patient is allergic to the medication and they still want to give it, then we have to dispense it and any potential reaction that happens all falls on the physician. If the physician didn't acknowledge that there was an allergy, and the pharmacist misses it and fills it anyway, then it falls on both the physician and pharmacist.

 

[ethyl]

At least you fixed his hypertension?!

 

[ethyl]

I would need something more than "ok". Our hospitalists type in quick little sentences like "patient tolerated Keflex in past" for a Rocephin order with PCN allergy. They give us something that actually tells us they're aware of the allergy. Pharmacy will take most of the blame for this error from management because the **** always slides down to pharmacy (but ultimately it's the physicians/hospital's liability insurance that will take the hit from the lawsuit). If it was your error, chalk it up as something never to repeat again... always call if there's a questionable allergy no matter how annoying your phone call might seem to a physician and no matter how slammed you're getting by orders building up.

Reminds me how private supplemental liability insurance is so important for us. A hospital could EASILY fire someone for this type of error, claiming they were negligent and leave them unrepresented in any lawsuit that might be directed towards them from the patient.

 

[farmadiazepine]

Pharmacist's fault. Hands down. What kind of pharmacist OK's enalapril for a patient who had a history of anaphylaxis to an ACE-inhibitor?

A pretend pharmacist.

 

[addelmike]

I also think this error would have to be looked at from a system-failure perspective. Did the PA just have alert fatigue? Did the PA think pharmacy would intervene if this were an issue? Did the pharmacist think the PA understood the implications of the allergy? Did the nurse fail to follow protocols?
Rather than saying that it was solely the PA's fault (although the error obviously started with the PA), I think the bigger question is how can you fix your protocols, ordering process, and administration protocols so that this kind of thing is caught next time.

 

[Chemistjoey]

No. If the physician acknowledges the fact that the patient is allergic to the medication and they still want to give it, then we have to dispense it and any potential reaction that happens all falls on the physician. If the physician didn't acknowledge that there was an allergy, and the pharmacist misses it and fills it anyway, then it falls on both the physician and pharmacist.

If this is the norm in american hospitals, pharmacists are nothing more than dispensing monkeys who can easily be replaced by computer robots. It seems as if the eight years of work completed to obtain a docotorate degree is useless, especially since a physician gets the final word in our " speciality". Something has to change here!

 

[BeLikeBueller]

If this is the norm in american hospitals, pharmacists are nothing more than dispensing monkeys who can easily be replaced by computer robots. It seems as if the eight years of work completed to obtain a docotorate degree is useless, especially since a physician gets the final word in our " speciality". Something has to change here!

This is a very narrow view. While the expertise of pharmacists should definitely be recognized, it is ultimately a physician who is taking responsibility for the care of the patient. I believe that the assumption that was made here (although wrongly so) was that the provider had discussed the allergy with the patient and had determined that there was not a true anaphylactic reaction. Pharmacists often don't have access to the information that is needed to take responsibility for care decisions. In this type of a situation, the pharmacist should have contacted the provider to get the necessary information, but that is not something that is necessarily readily accessible to the pharmacist in all practice settings.

Hopefully, with the advent of comprehensive EMRs, pharmacists will begin to have greater access to the information that we need to help contribute to rational medication use, but that will be a process that will take many years to be fully implemented nationwide. The primary focus of pharmacists right now is patient safety. In general (with the exclusion of certain clinical settings) pharmacists aren't making treatment decisions - but we are ensuring that a patient's pharmacotherapy is safe and rational. And that is an incredibly important job, as is evidenced by this very incident.

 

[BenJammin]

It's the pharmacist's fault 100%. It was the pharmacist that gave the final OK on giving the drug to a patient with a recorded allergy of anaphylaxis. It's going to be the defense attorney that looks at the PharmD and says to the jury that the PA couldn't dispense...it was the pharmacist that dispensed it and authorized this drug that caused so-and-so to die/get injured badly.

But in the end, who cares? I'm more interested in how we make sure this never happens again.

 

[farmadiazepine]

No. If the physician acknowledges the fact that the patient is allergic to the medication and they still want to give it, then we have to dispense it and any potential reaction that happens all falls on the physician. If the physician didn't acknowledge that there was an allergy, and the pharmacist misses it and fills it anyway, then it falls on both the physician and pharmacist.

If a physician acknowledges that a patient had anaphylaxis to an ACE-I and still wants to give enalapril, um F*CK NO, you DON'T dispense it. You're not a doctor's puppet that does whatever they save. You don't dispense anything which will put a patient in harm. All it takes is a call to the doctor to clarify this. I don't understand why seeing "OK" in a computer stops someone from actually getting in touch with a prescriber.

And part of this problem is that sometimes we are just too computer heavy. The computer is not a substitute for real communication. I know people who type "OK" into DUR fields all day long. That doesn't mean they are actually looking at the interaction all the time. It's the RPh responsibility to look at all these things.

And come on, basic common sense here. Anaphyaxis to ACE inhibitor. Enalapril is an ACE inhibitor.

 

[Sparda29]

If a physician acknowledges that a patient had anaphylaxis to an ACE-I and still wants to give enalapril, um F*CK NO, you DON'T dispense it. You're not a doctor's puppet that does whatever they save. You don't dispense anything which will put a patient in harm. All it takes is a call to the doctor to clarify this. I don't understand why seeing "OK" in a computer stops someone from actually getting in touch with a prescriber.

And part of this problem is that sometimes we are just too computer heavy. The computer is not a substitute for real communication. I know people who type "OK" into DUR fields all day long. That doesn't mean they are actually looking at the interaction all the time. It's the RPh responsibility to look at all these things.

And come on, basic common sense here. Anaphyaxis to ACE inhibitor. Enalapril is an ACE inhibitor.

So you're telling me if you got an order for Zosyn and the patient has a history of hives in rxn to penicillin, you're going to call the prescriber even if the prescriber wrote down MD aware of PCN allergy.

What if the rxn to ACE-inhibitors was simple urticaria? Would you still not dispense?

Now as for the dispensing, this point is moot because the pharmacist never actually dispensed it. The nurse/prescriber could have still gotten it out of the Pyxis without the pharmacist verifying the order.

 

[JoBreeze]

So you're telling me if you got an order for Zosyn and the patient has a history of hives in rxn to penicillin, you're going to call the prescriber even if the prescriber wrote down MD aware of PCN allergy.

What if the rxn to ACE-inhibitors was simple urticaria? Would you still not dispense?

Now as for the dispensing, this point is moot because the pharmacist never actually dispensed it. The nurse/prescriber could have still gotten it out of the Pyxis without the pharmacist verifying the order.

Really? It's anaphylaxis. What do you not understand?

Farmadiaz and BenJammin have it right.

Are you or are you not the drug expert on the team?

Theres a bleed on CT and the patient gets tPA, does radiology sit around and blame the ED for not picking that up?

 

[confettiflyer]

You guys suck at RCA

 

[mustang sally]

So you're telling me if you got an order for Zosyn and the patient has a history of hives in rxn to penicillin, you're going to call the prescriber even if the prescriber wrote down MD aware of PCN allergy.

What if the rxn to ACE-inhibitors was simple urticaria? Would you still not dispense?

Now as for the dispensing, this point is moot because the pharmacist never actually dispensed it. The nurse/prescriber could have still gotten it out of the Pyxis without the pharmacist verifying the order.

What's even the point in verifying orders when others can override and get stuff out of the machine anyway? That's what I want to know--used to think it was pointless to sit there and verify everything from the overnight that had already been given to patients, but anyway...I would say it was at least worth a call to see if they had already given the enalaprilat yet or not. True, the PA did type OK but who knows if he/she even read the screen or the what the allergy was. Anaphylaxis should set off enough warning bells to pretty much always warrant a call in my mind.

 

[benjee]

If a physician acknowledges that a patient had anaphylaxis to an ACE-I and still wants to give enalapril, um F*CK NO, you DON'T dispense it. You're not a doctor's puppet that does whatever they save. You don't dispense anything which will put a patient in harm. All it takes is a call to the doctor to clarify this. I don't understand why seeing "OK" in a computer stops someone from actually getting in touch with a prescriber.

And part of this problem is that sometimes we are just too computer heavy. The computer is not a substitute for real communication. I know people who type "OK" into DUR fields all day long. That doesn't mean they are actually looking at the interaction all the time. It's the RPh responsibility to look at all these things.

And come on, basic common sense here. Anaphyaxis to ACE inhibitor. Enalapril is an ACE inhibitor.

I agree. Pharmacist SHOULD NEVER dispense it even the PHYSICIAN NOT THE PA OK it on the phone or in person because this is a SERIOUS REACTION which can cause DEATH. There are other IV drug which can lower bp which you can recommend . Also, I would be more careful when dealing with PA orders since they may not be under supervision of a physician all the time. In this case, the physician may not even know the pt has this allergy history. If the physician insists, the pharmacist should go further up ie , get your own supervisor and the physician's supervisor involved.

 

[MackandBlues]

You guys suck at RCA

I concur.

 

[MackandBlues]

You know what they say about assuming... it makes an ASS out of U and ME.

I know, I was quoting someone else.

 

[fab4fan]

This is why prescribers should not be given the authority to override DURs and allergy information in the computer system. This is the job of the pharmacist. If the prescribers wrote down for IV enalapril and then the next check was the RPh, there would have been a stop and the RPh would not dispense and question the prescriber.

Bad on the part of the PA who overrode it. PA's go to school for such little time and have very little knowledge about drugs and pharmacology and all that ish. Ask them to name members of the ACE-inhibitor class and I'm sure they won't know or will have a tough time doing it.

But also bad on part of the RPh. WHY wouldn't you go back and question it? Anaphylaxis alert comes up in the computer and your first job is to NOT DISPENSE.

Yea its an error by a doctor, but PA should of caught it, if not, then RPh should have caught it.

I can't blame the nurse on this. The person who gets paid the least money should not be at fault at all, especially after going thru checks by a doctor, PA, and RPh.

It is incumbent on nurses giving meds to check for allergies. You can't assume that just because the med was OK'd by the PA and pharmacy that it's OK if there's documentation of allergy/sensitivity. Nurses are the last chance to catch a prescribing error.

 

[Its Z]

The first fault is the environment trying to identify whose fault it is.

We're human. We're going to make mistakes. When you deny this fact, your organization is doomed to fail.

Errors occur due to system failure. And when you create a punitive environment surrounding errors, you will never improve and prevent future errors from occurring. It's this kind of environment where cooperation and corroboration do not exist to prevent errors and improve process.

No one goes to work trying to intentionally hurt patients.

 

[Digsbe]

I'd say both the pharmacist and PA/supervising physician are liable. If there is anything I've learned it's that if your license or malpractice suit is on the line don't risk things by assuming or putting too much good faith into someone else. Even if the PA had documented why they thought it was OK despite overriding the allergy check I would still call and document things myself. The medications dispensed under the pharmacist's license are the pharmacist's responsibility. The prescriber also has their responsibility, but both parties are at fault and should be liable.

 

[thephoenician88]

The first fault is the environment trying to identify whose fault it is.

We're human. We're going to make mistakes. When you deny this fact, your organization is doomed to fail.

Errors occur due to system failure. And when you create a punitive environment surrounding errors, you will never improve and prevent future errors from occurring. It's this kind of environment where cooperation and corroboration do not exist to prevent errors and improve process.

No one goes to work trying to intentionally hurt patients.

thank you!

everyone in here is blaming everyone else. The fact is, a mistake happened in the system. You can all sit here and analyze the situation all you want, but you weren't at that ER, you weren't in that pharmacists shoes, and you're certainly not there now.

Should it have been dispensed, maybe not, but if that's the way allergic reactions are handled at the hospital, then who are all of you to say otherwise?

 

[pinipig523]

The dose was correct, Enalaprilat 1.25 mg IVpush one time dose. In retrospect, why not give a Labetolol IV push or a Hydralazine IV push?

Maybe the patient was pregnant 1t or 2t and labetalol is C/I because of renal teratogenicity... or maybe the patient was a high risk CAD pt in which hydralazine is C/I.

 

[Throwaway_Stigma]

wrong forum

 

[Scotttyd]

both are at fault - this happens all the time in my setting - I call every time (or just walk over from my desk in the ED) - many of the times they get alert fatigue like the rest of us and don't realize the severity of the reaction. I would rather be safe than sorry, I have never had a MD complain I was asking them too many questions when it comes to patient safety. If there is a law suit you better believe the pharmacist will be named in the lawsuit. If we didn't have to verify orders and give it our blessing, what the hell are we doing as a profession?