Medication Error: Who's fault is it?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
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.
fyi - ace-I are category X and labetaolol is the drug of choice in a pregnant patient.

study up buddy

Members don't see this ad.
 
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.
yes I would, I did last night - MD stated "Crap, I misread it" then called me later that night again to say thanks. That is why we work as a team. In our ED the RN's are not to pull meds until pharmacy verifies it (I sit right next to the pyxis) for this VERY reason
 
fyi - ace-I are category X and labetaolol is the drug of choice in a pregnant patient.

study up buddy

Actually, they're category D now...don't ask me when this happened. I think it's been within the past year, but ace-inhibitors are in fact, category D. Just a little drug info update.
 
Members don't see this ad :)
Actually, they're category D now...don't ask me when this happened. I think it's been within the past year, but ace-inhibitors are in fact, category D. Just a little drug info update.
why thank you - but still - just saying, i still would not use it :)
 
  • Like
Reactions: 1 user
Sparda is all about personal responsibility and doing things his way until he almost helps kill someone and then he's all like " just following order" and doing what the system says.

But yeah. I put most blame on the pharmacist. Yesterday an office sent over a E-rx for augmentin for an allergic patient. This is after the patient told them multiple times she was allergic and they overrode the DUR on their side. Luckily I caught it when filling. Sure most of the "allergies"'are BS but ill still verify each one
 
It's obviously the patient's fault for being allergic.

And ACE inhibitors end in "-pril" - thus, enalaprilat is not an ACE inhibitor, so they should be safe.
 
It's obviously the patient's fault for being allergic.

And ACE inhibitors end in "-pril" - thus, enalaprilat is not an ACE inhibitor, so they should be safe.
I sure hope you are joking (I don't know you but that sounds like a smart ass comment I would say)
 
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.

Overall, I think everyone must take some responsibility for the mistake. As a pharmacist, I totally agree that the override and order SHOULD have warranted a phone call at the least. It's part of our job, as medication experts. We should not fault PA's and nurses for not "knowing" this stuff as well as we do, although they should certainly learn more as they gain more experience. That's why we're supposed to work with them and offer suggestions, alternatives based on our extensive pharmacological knowledge. ABSOLUTELY, the pharmacist should have called the order into question.
Fab4fan is also correct in that the nurse, as the last chance provider, should also have caught and questioned the order.

Recently where my husband (pharmacist) works, someone was ordered sulfamethoxazole/trimethoprim who also had a sulfa allergy. The allergy got by the dispensing pharmacist and drug was administered for a couple of days. When a nurse noticed the allergy and questioned the order (before patient had any reaction yet) by calling down to the pharmacy, a second pharmacist dismissed it saying something like if the patient hadn't had a rash or anything by now it was probably ok to give. (?????????????????????????????????????) Needless to say, said patient eventually broke out in hives after several days of taking SMZ/TMP. My husband, a pharmacist at the facility but not one of the two involved, was totally beside himself, especially with the second pharmacist's response. Unfortunately, even the nurse's attempt to question was not enough.

All are responsible but pharmacy even more so when it comes to medication errors that could have been at least caught and questioned before others decided to administer.
 
  • Like
Reactions: 1 user
A few thoughts from the MD side...

The OP didn't know what the allergy was to the medication. If the computer said that patient had a history of anaphylaxis, then pharmacist gets some of the blame. Otherwise, it could be something as stupid as the patient got a tingly feeling in the hands one time after taking lisinopril and so decided they were allergic to it.

That said, with such a useless override reason, I think calling the prescriber would have been a good idea.

Lastly, my EMR gives me some type of drug error message with pretty much everyone who is taking more than 2-3 things so I'll admit I am not as dilligent about my reasons for overriding as I should be. Hopefully the PA in this case learned to do better.
 
A few thoughts from the MD side...

The OP didn't know what the allergy was to the medication. If the computer said that patient had a history of anaphylaxis, then pharmacist gets some of the blame. Otherwise, it could be something as stupid as the patient got a tingly feeling in the hands one time after taking lisinopril and so decided they were allergic to it.

That said, with such a useless override reason, I think calling the prescriber would have been a good idea.

Lastly, my EMR gives me some type of drug error message with pretty much everyone who is taking more than 2-3 things so I'll admit I am not as dilligent about my reasons for overriding as I should be. Hopefully the PA in this case learned to do better.

This is pretty much the best answer.

Nothing grinds my gears more than a codeine "allergy". But you better believe it needs to be checked up on--- not necessarily by calling the MD, but by looking at past medication history, calling the nurse, talking to the patient, and finally, calling the prescriber.

But anaphylaxis? Lol, no. That's not getting overrode. If they want it that bad they are going to have to deactivate the allergy.
 
This is pretty much the best answer.

Nothing grinds my gears more than a codeine "allergy". But you better believe it needs to be checked up on--- not necessarily by calling the MD, but by looking at past medication history, calling the nurse, talking to the patient, and finally, calling the prescriber.

But anaphylaxis? Lol, no. That's not getting overrode. If they want it that bad they are going to have to deactivate the allergy.

I was always under the impression that a true opiate allergy was exquisitely rare, like not clinically relevant rare. But "it makes me itchy" or "it hurts my stomach" is always a popular allergy symptom
 
I was always under the impression that a true opiate allergy was exquisitely rare, like not clinically relevant rare. But "it makes me itchy" or "it hurts my stomach" is always a popular allergy symptom
yea true opoid allergies are very rare - like as in a couple case reports
 
Top