I caught a med error last night!
I was at my overnight hospital rotation. Patient's home med list was collected and entered into Epic. We were at final verification (I'm not allowed to verify as an intern, so I was watching my preceptor verify) and I asked my preceptor, "Did I read that right? Venlafaxine 750 mg?"
For those who are unfamiliar with venlafaxine (Effexor), a typical dose is around 75-150 mg; the max dose for any indication is around 225-300mg. So 750 is a LOT.
Fortunately, this patients outside medical records were accessible in her profile, so we were able to see that she had been getting 150 mg prior to her hospital stay. Called the provider, provider authorized change, changed it to 150. Most likely it was entered incorrectly somewhere along the line. (Personally, my guess is that someone hand-wrote the 150 dosage to be transcribed into the EMR by someone else, but their 1 looked like a 7.)
It's possible this could have been caught further down the line. For example, we usually only send up 24h worth of meds at a time, and each pill is individually packaged, so maybe the nurse would question having to open 5 packages of one med to get the desired dose, rather than going up to a higher strength (there isn't one for venlafaxine, but you might wonder if you didn't know). But what's the likelihood they would speak up about that? Or the patient might have caught the error when she's told to take five capsules of venlafaxine, but it's probably not a good idea to rely on the patient for catching med errors! So essentially, this was the last possible step in the chain where someone could have caught it, because after final verification we tube it up to them.
I'm just really, really proud of myself.