Medication errors

[pharmacology888]

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I just read this article from Pharmacy Week and one of the pharmacists was quoted saying “We are told to never apologize for giving a wrong prescription because it automatically implies guilt. I suppose the company wants to leave that to the attorneys.” However, I was taught to always apologize if a drug error occurred. Any thoughts?
http://www.consumeraffairs.com/news04/2007/11/rx_errors.html

Also, one point the article makes is the fact that doctors need to improve their handwriting. Have you guys ever misread a prescription? What was prescribed and what did you dispense? Sorry for the questions, I'm just trying to gain more experience as to what kind of errors usually occur so I can be more aware of these similar errors in the workplace.

thanks

 

[futuredruggist]

I think medication errors must be very rare in the US because politicians often say the US has the best health care system in the world. Michael Moore is an outlier so don't worry about him.

 

[OUTexan]

We had a Rx the other night that was Seroquel 25 mg. We translated the sig to be take 1/2 tablet every 4 hours as needed for 1 week, then increase to 1 tablet every 4 hours as needed. I thought this was a very strange way of dosing and the pharmacist looked it up and figured the doctor knew what he was doing. Plus it was about 8 p.m. so you can't call the doctor. We let it go and the mother called and asked if it was suppose to be every 4 hours or take at 4 p.m. We realized we made the mistake. The P.M. was written "pm" and that can look a lot like "prn" especially if there are no periods.

 

[soyroger]

I think medication errors must be very rare in the US because politicians often say the US has the best health care system in the world. Michael Moore is an outlier so don't worry about him.

I cant' tell if you're being serious or sarcastic cause this is so off the mark it isn't even funny. Medical errors are estimated to be the cause of tens of thousands of deaths per year. As for not apologizing, I've seen some doctors make errors but never heard them apologize. With the threat of litigation for health care mistakes I'm not shocked he was advised not to apologize.

 

[futuredruggist]

I was being sarcastic.

 

[pharmacogenomic]

I think medication errors must be very rare in the US because politicians often say the US has the best health care system in the world. Michael Moore is an outlier so don't worry about him.

I gotta agree with the previous poster. Medication errors are extremely common & one of the most frequent reasons for hospital admissions.

Personally, I apologize each & every time I make a mistake. I'm very careful - I apologize for the situation - not take the blame. Those are two different things.

Each error has its own set of circumstances. However, no matter the circumstance, the patient has been inconvenienced, the treatment set back, the physician needs to be informed & possibly more testing might be required.

An apology for all that is expected & if you pursue actual studies during your school endeavors, you'll find that those who apologize for errors (whether its pharmacy, medicine, dentistry, etc....) have fewer malpractice complaints & judgements.

 

[gaba101]

one time i think this new pt was supposed to get garamycin ointment. MD's handwriting was real sloppy. tech interpretted it as tobramycin (I think this was the faulty drug, it's been a while). pharmacist approved the 4-pointing. when i went to counsel her, i noticed she was using this for her eye and she was like oh i didn't know i could put gentamicin ointment in my eye. So i told her to hold still for a sec while i go double check "with the doctor." i went to double check hte original prescription, it did look like tobramycin but i double checked with clinical pharmacology and tobramycin ointment is not used for eye. i was in the middle of calling the doctor when the pharmacis twas like just give her the gentamicin ointment. geez. poor way of handling the situation, in my opinion. 👎

 

[pharmacia07]

i think there should be a check and balance to prevent medication errors...we can learn by documentation or reprogramming the way we handle our communication for the long term..............

 

[Phlame217]

Soon, hand written scripts are going to be thing of the past, atleast for CVS. It is already prevolent in private clinics, but hospitals are catching up. What I am talking about is computer generated scripts and electronic submission. On a normal day, I see probably 40-60 scripts a day that are submitted electronically up from 10-20 a few months ago. Also probably 1/3 scripts brought in by hand are printed scripts vs handwritten where as about 1/6 were a couple of months ago. The pharmacy I work it is a "slower" one as we do about 1300 scripts a week where as our sister store down the street does 2700 a week.

 

[Old Timer]

Electronic prescribing is not a panacea. I have just as many errors from electronic prescriptions as with written prescription, they just don't revolve around handwriting analysis.

Within 3 days I received from a doctors office three scripts for the same patient:

Tegretol XR 400 mg BID
Teregtol 200 2 tabs qid
Tegretol 200 2 tabs BID

All electronic......

 

[Phlame217]

I'm not saying it alone is the solution, it still requires an operator on the other side who is educated enough to understand and use the software, but it is a big step in eliminating one of the larger areas where errors are derived from.

 

[tussionex]

i went to double check hte original prescription, it did look like tobramycin but i double checked with clinical pharmacology and tobramycin ointment is not used for eye. 👎

check your facts on that one.

 

[OUTexan]

We got a script dropped off to us that was typed on paper. The top heading had the clinic information and then the patient name, address and date of birth. Then came the Rx info:

Drug: Acyclovir 400 mg Quantity: 12

Sig: BID

Comments: 1t;tid;prn;fever blisters

Electronic signature


Why do pharmacists have to verify everything before it goes out but the doctor doesn't seem to have to verify everything that goes out to the patient. Plus the receptionists that call in prescriptions, but only an intern or pharmacist can write them down. Why is this? Should we put pharmacists in the doctor's office to fix this problem?

 

[Phlame217]

//begin sarcasm
Its because certified medical technicians are "too expensive" for the medical offices
//end sarcasm

Like i said before, it requires operators educated enough to use the software. If things worked as they were supposed to, the doctor himself would call in every script but in the in-and-out clinics and whatnot, the receptionist picks up the majority of the paperwork... or voice work.