Save by the order!

[Onion Bunny]

Just thought I like to share this with you, this happened today afternoon... a near miss almost turns into a dispensing error

A script for Vascace 5mg tablets (plus other items but they're not important here), a dispenser labelled it, a technician dispensed it, and I checked and bagged it... thought nothing more of it, until the afternoon order turned up, and the technician found 2 boxes of Vascace 5mg tablets in the order, but she remembered picking Vesicare 5mg tablets off the shelf! And I definitely remembered checking some Vesicare and putting them in a bag! So now the 3 of us frantically searched the computer and try to find out which patient it was. Luckily I know it's a surgery script and so the patient hasn't picked it up yet. At the end we found the bag, after double checking the script and confirmed the wrong med was put in (with the correct label) ...

I admit it's my negligance, namely, I've never seen Vascace before (during my 3 year of qualifying), and so when I first saw the script of Vascace 5mg tablets, my brain just automatically 'switches' it to the closest word that I do know, which is Vesicare 5mg tablets.

I guess lessons to be learnt here:

- Never assumes anything!
- Know how to spell the name of drugs correctly and double check the package and the label

[Zoggite]

I remember chasing a patient all the way to the bus stop, convinced that I'd given her methylprednisolone instead of methylprogesterone...I hadn't, but the patient was reassured by the fact that I would have been prepared to admit to a mistake, and I'd always prefer to check once too often than once too few...

[Defblade]

I was saved by checking off the order once....

Rx for methotrexate 2.5mg tabs, looked at first open bottle, 10mg. So I picked up and used the other open bottle.

Order came in, 2.5s were in blisters (first time I'd seen them in blisters). I thought "Hmm, sure I gave them out of a bottle this morning". Check shelf, 2 open bottles of 10mg. "Faece" or something less medical.

Sorted out, including GP, patient in again a couple of days later with an unrelated script, telling me about the extra blood tests she'd be having and thanking (!) me.

1) Never assume.
2) Worth checking off the order yourself if possible.
3) Patients really don't mind when they find out about problems from you, as Zoggite says too.





NB, if the Inspectorate are reading, this actually happened to a friend of mine who has now retired and died, and I have used the first person purely as a narrative device.

[exSAgrad]

I was saved by checking off the order once....

Rx for methotrexate 2.5mg tabs, looked at first open bottle, 10mg. So I picked up and used the other open bottle.

Order came in, 2.5s were in blisters (first time I'd seen them in blisters). I thought "Hmm, sure I gave them out of a bottle this morning". Check shelf, 2 open bottles of 10mg. "Faece" or something less medical.

Sorted out, including GP, patient in again a couple of days later with an unrelated script, telling me about the extra blood tests she'd be having and thanking (!) me.

1) Never assume.
2) Worth checking off the order yourself if possible.
3) Patients really don't mind when they find out about problems from you, as Zoggite says too.





NB, if the Inspectorate are reading, this actually happened to a friend of mine who has now retired and died, and I have used the first person purely as a narrative device.

Dr recently put through script for 10mg methotrexate, take 4 weekly... Picked up as error as we have policy to only prescribe in multiples of 2.5mg which we stock. ie should have been methotrexate 2.5mg take 4 weekly etc

[cymru72]

Just thought I like to share this with you, this happened today afternoon... a near miss almost turns into a dispensing error

A script for Vascace 5mg tablets (plus other items but they're not important here), a dispenser labelled it, a technician dispensed it, and I checked and bagged it... thought nothing more of it, until the afternoon order turned up, and the technician found 2 boxes of Vascace 5mg tablets in the order, but she remembered picking Vesicare 5mg tablets off the shelf! And I definitely remembered checking some Vesicare and putting them in a bag! So now the 3 of us frantically searched the computer and try to find out which patient it was. Luckily I know it's a surgery script and so the patient hasn't picked it up yet. At the end we found the bag, after double checking the script and confirmed the wrong med was put in (with the correct label) ...

I admit it's my negligance, namely, I've never seen Vascace before (during my 3 year of qualifying), and so when I first saw the script of Vascace 5mg tablets, my brain just automatically 'switches' it to the closest word that I do know, which is Vesicare 5mg tablets.

Nearly made an error similar to this myself recently. I was about to give out a box of tamoxifen 20mg labelled and dispensed by someone else when luckily I double checked and noticed that the script was in fact for TENOXICAM 20mg !!! Dose is same at one daily. Haven't seen this NSAID given out for years and years!!!

[Sandman]

Once woke up in a cold sweat one night believing I had dispensed Raloxifene tablets the previous day instead of Reboxetine (or vice versa, it was a while ago). Turned out I hadn't after contacting the patient the next day, but needless to say I have quadruple checked any scripts for either of these drugs ever since.

I think everyone has their own combination of drugs that always causes a little mental block when they dispense/check.