Retail Pharmacy -- Common Medication Errors ?

[amlodipine1234]

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Hi!
Wondering what common med errors people have seen over the years so that I can work to not make those? For example, I've heard of several people dispensing Klor Con vs Potassium Chloride ER; or dispensing a cream instead of an ointment. I always give high risk medications like methotrexate an extra check before dispensing, but I'm just trying to improve my knowledge base and trying to increase my awareness of common med errors.

Thanks!

 

[Dred Pirate]

any of the look a like sound a like meds - selling the wrong person's meds to another is what I have seen cause the biggest concerns from companies

 

[WVUPharm2007]

Hydroxyzine and hydralazine are a bad mixup that happens a lot.

 

[Rouelle]

Depakote ER and DR are mixed up a lot

 

[gwarm01]

Hydroxyzine and hydralazine are a bad mixup that happens a lot.

This is a great example of a simple and easy mistake that can have deadly effects. This is, indeed, a delicious salad.

 

[VA77]

These are the ones I have seen.
1. Hydroxyzine vs Hydralazine
2. Risperidone vs Ropinirole
3. Folic acid vs MTX.

My former boss actually got reprimanded by BOP on #1.

 

[PA_dud3]

When I first started I used to mix up Isosorbide Mononitrate and Dinitrate every now and again when counting, never let it get to the patient however. Thankfully I don't mess up too often now that I have some experience 🙂

 

[rphola123]

Hi!
Wondering what common med errors people have seen over the years so that I can work to not make those? For example, I've heard of several people dispensing Klor Con vs Potassium Chloride ER; or dispensing a cream instead of an ointment. I always give high risk medications like methotrexate an extra check before dispensing, but I'm just trying to improve my knowledge base and trying to increase my awareness of common med errors.

Thanks!

Klor con and potassium chloride are the same thing

 

[ericn2k3]

Klor con and potassium chloride are the same thing

Maybe Klor-con Vs Potassium Citrate?

 

[johnpharm01]

Hi!
Wondering what common med errors people have seen over the years so that I can work to not make those? For example, I've heard of several people dispensing Klor Con vs Potassium Chloride ER; or dispensing a cream instead of an ointment. I always give high risk medications like methotrexate an extra check before dispensing, but I'm just trying to improve my knowledge base and trying to increase my awareness of common med errors.

Thanks!

ISMP is really a great source of information regarding medication errors and how to avoid them. The same ones ISMP discusses happen in practice. Another good source of best practices maybe your employer. I applaud your effort in taking a pharmacist's responsibility seriously. That being said:
1. wrong unit of measure on anbx suspension: tablespoonful when should be teaspoonful or mls in place of teaspoonful or vice versa
2. wrong dosage form on drugs with multiple forms metoprolol products
3. wrong patient: name matches but dob doesn't i.e. father and son
4. refrigerated drug put on shelf unrefrigerated
5. wrong prescription bagged with wrong leaflet patient takes someone else's med for a month

 

[owlegrad]

Wellbutrin SR vs XL is one that I have made more than once sadly.

My first error ever was mixing up atorvastatin-amlodipine with atorvastatin-benazepril. In general I think combination medications are extremely easy to mess up and need extra focus to prevent errors.

 

[owlegrad]

Vitamin d2 vs d3 is another one I have seen very, very frequently.

 

[PharmtoCS]

Patients with the same first and last names.

 

[gwarm01]

In hospital practice I saw some issues with dosing in combination products like Zosyn and Augmentin. Often dosing is recommended in the antibiotic component, but you may see doses for the entire product. Just be sure of what component they mean, especially if it is in mg/kg.

 

[Dreamer716]

Hi!
Wondering what common med errors people have seen over the years so that I can work to not make those? For example, I've heard of several people dispensing Klor Con vs Potassium Chloride ER; or dispensing a cream instead of an ointment. I always give high risk medications like methotrexate an extra check before dispensing, but I'm just trying to improve my knowledge base and trying to increase my awareness of common med errors.

Thanks!

Lol some clarity on the Klor Con vs Potassium Chloride ER. They're not substitutable?

 

[radio frequency]

I think overriding DURs that are important without investigating further and not glancing at the patient’s med list for interactions or other issues before dispense is a huge and overlooked issue and could land you in trouble.

Here’s some others I’ve seen:

-Dispensing amox-clav 875 mg or 500 mg instead of amoxicillin 875 mg or 500 mg, and vice versa.

-IR vs ER oxycodone formulations

-Dextroamphetamine vs amphetamine-dextroamphetamine often gets entered wrong

-Wrong patient’s prescription gets scanned in at drop off in a group (examples: sent from nurse together in a group, but one is for a different patient, parents drops off scripts for multiple family members at once)

-Days supply screw ups (common, but avoidable usually and a hassle to deal with later)

-Wrong quantity dispensed for weird pack sizes (example: is a box of Diastat with two syringes 1 or 2?); if this is a control which it inevitably is, then it’s even more of a problem

-Always call on any vet meds you have questions about; sometimes dosing is really weird for animals and if you’re unfamiliar you don’t want to screw it up.

 

[lord999]

Sinemet and Sinemet CR (methyldopa) both on the misfill and misprescribed. This is one of the few times where even retail outpatient pharmacists should check the patient's profile history as getting the wrong one either is ineffective or worse cuts down the effectiveness.

 

[JustFillIt]

So..... Klor con vs pot cl ER. - 99.9% of cases the doc (or confused ma) who sent the Rx in just wants the pt to get potassium in any formulation they just want to get the order over with. However I do believe the difference is an IR formulation vs an ER formulation. I have worked with retail pharmacists who just change them all to ER and only dispense ER formulations and just call it good. In my experience though - I have ran into a patient who demanded potassium citrate due to kidney stone issues. I am the type of pharmacist who is a crowd pleaser so I ordered him in the pot citrate and moved on.

Here are the rx’s That I spend an extra 30 seconds on to ensure that I did not make a mistake:

Diltiazem: in all my experience I have never figured out what the hell is going on with all the diltiezems... many are not interchangeable. Check your gpi numbers before subbing any diltiazem.

Sulfasalazine - one of the most easy look alike sound alike. Make extra sure you don’t dispense sulfadiazine.

Warfarin - this drug is dangerous if not used correctly. Just double check name, dob, drug, dose, sig. F days supply.... just get that stuff right.

Have a “dummy bottle” of ab suspensions with the fill level marked. For each type. That way you can check the concentration of your suspensions before they go out the door. This is if you have your techs do your suspension mixing.

Others have been previously mentioned

 

[croquemonsieur]

So..... Klor con vs pot cl ER. - 99.9% of cases the doc (or confused ma) who sent the Rx in just wants the pt to get potassium in any formulation they just want to get the order over with. However I do believe the difference is an IR formulation vs an ER formulation. I have worked with retail pharmacists who just change them all to ER and only dispense ER formulations and just call it good. In my experience though - I have ran into a patient who demanded potassium citrate due to kidney stone issues. I am the type of pharmacist who is a crowd pleaser so I ordered him in the pot citrate and moved on.

Check your gpi numbers before subbing any diltiazem.

Sulfasalazine - Make extra sure you don’t dispense sulfadiazine.

Huh?

 

[JustFillIt]

Huh?

What?

 

[pharmBear]

Tip for new retail pharmacist
-If you get a diltiazem script phone transfer, I recommend asking for the ndc. Most are not interchangeable and will save you a future headache.

 

[Sine Cura]

One thing I look at is what from what office these scripts originate. For example mental health clinics will never write an Rx for hydralazine so seeing a psych prescriber write for that would stand out (actually it may have been typed wrong). Same thing for hydroxyzine from a cardiologist (they would probably not write for hydroxyzine). Also how something is typically dosed (tramadol vs trazodone; Macrodantin vs Macrobid)

Morphine ER incorrect formulation is something else to consider (Kadian vs Avinza vs MS Contin). Morphine oral solution is also another one as people see 20/1 as 20/5 or vice versa for whatever reason. Oxy-IR is another one as technically that is a capsule, not the tablet.

I see techs **** up budesonide nbs qty all the time too

But Klor Con vs "ER," what does that mean? Klor-Con, K-Tab and Klor-Con M solid tablets are all ER. Klor-Con M is microencapsulated vs wax-matrix for the other two

 

[zelman]

In hospital practice I saw some issues with dosing in combination products like Zosyn and Augmentin. Often dosing is recommended in the antibiotic component, but you may see doses for the entire product. Just be sure of what component they mean, especially if it is in mg/kg.

Also, weight based sulfamethoxazole/trimethoprim is dosed by trimethoprim.

 

[maria1oh]

Warfarin 1.0 mg vs 10mg. 2.5 vs 7.5 mg.

I remember several years ago I worked in a medicaid area and the medicaid plan covered vit d2 50,000 but not d3 50,000. They switched it automatically - tech said they do it all the time because they don't even make d3 as 50,000 (we never had it in stock but later found out it does exist).

Proair vs ventolin was another automatic switch made due to insurance/medicaid plan. Doxycycline hyclate and monohydrate was another automatic switch. Switching cream and ointment or tablet and capsule was usually automatic. If doc keeps writing for bactroban cream but insurance only covers ointment it got switched. Switching birth control manufacturers was never an issue.

Now I'm in a rich/snobby area where people are much more demanding so these switches don't happen. If it's not covered then we cash it out and they usually just pay for the vitamin d3 or we offer to call doctor to switch and they say nah I just want it now. Also no switching NDC on birth controls because they flip out and demand a particular ndc. And insist they don't want anything made in India or China. If we don't have it they transfer it somewhere else. I know a store in the area that did misfill report per rx sup bc patient was so mad we switched her manufacturer on birth control. There was no daw 2 on script but apparently patient claims to have said she wants same manufacturer and rph failed to put it in as daw 2. I have had customers bring back rx saying we filled it wrong because doctor wrote for keflex tablets and not capsules.

 

[jack rabbit]

Metformin vs. metformin ER
Naproxen vs. naproxen DR

 

[Greeney]

Metformin osmotic release vs metformin modified release. But you know the prescriber's office really just wanted metformin ER and decided to pick a random formulation from their E-Rx system that costs the patient an arm and a leg and isn't interchangeable with regular ER.

Can't blame them though. The numerous non-interchangeable formulations can be complicated even for us pharmacists....I'm looking at you diltiazem and nifedipine.

 

[pharmBear]

Metformin osmotic release vs metformin modified release. But you know the prescriber's office really just wanted metformin ER and decided to pick a random formulation from their E-Rx system that costs the patient an arm and a leg and isn't interchangeable with regular ER.

Can't blame them though. The numerous non-interchangeable formulations can be complicated even for us pharmacists....I'm looking at you diltiazem and nifedipine.

Note the osmotic release is nothing special and is definitely not covered by insurance. I have seen pharmacy staff send PAs to provider office when a quick phone call would save everyone a headache

 

[maria1oh]

No such thing as a "quick phone call" to change metformin osm to ER when dealing with a large hospital or health care center. Try calling cleveland clinic. Wait on hold for 5 minutes to talk to operator. Then another 10 minutes to get connected to office to speak to secretary who will simply pass along the message to doctor who may or may not call you back.

 

[txpharmguy]

"Osmotic formulation not covered. OK to use standard ER formulation per Dr." and move on

 

[JustFillIt]

I don’t ever change anything not considered TE between drugs. Well - I will interchange proair/vent/provent if insurance wants me to.

I never wait in call ques either.... I have my techs do that mess!

Seriously though, if a patient had an adr and the drugs were not TE, a lawyer with some smarts could eat you alive