Drug Errors

[Zoggite]

Originally Posted by admin

Notes on drug increases, what kind of place gives you the time to do that? Show me it and I'll work there.

Is that a promise? exit 22a off the A55, turn left at the roundabout, then we're at the 2nd set of traffic lights!
how do you like your tea- milk and 2 sugars?

[Steve G]

Originally Posted by admin

. Notes on drug increases, what kind of place gives you the time to do that? Show me it and I'll work there.

Or, come off the M20 at junction 4, down the A228 towards Rochester and turn left after the first roundabout.

[kemzero]

Colleagues
I do empathise with the guy from Lloyds , but I believe this case will set an unwanted precedence, apparently there is a similar case in the offing.

Its imperitive that pharmacists are absolutely sure about the doses they are dispensing, there was a case back in the 70's , both the GP & P'cist were culpable..its just the way things are and I think they'll get worse particularly with remote supervision...if one is not sure its always best to refer at least you would have confirmed the dose and logged it accordingly -clinical governance systems will come in handy if a p'cist is involved in a negligence case such as the dexamethasone...so if an irate GP says he wants an overdose, document then dispense (?)

[Linnear]

What about The Migril Case?

We were told that the pharmacist was found to be more in error because the fact that he had rung the Dr proved he knew the dose was wrong.

[johnep]

The Migril case was important to pharmacy because it established in law the right of the pharmacist to challenge the Dr and refuse to dispense a script unles changed. Typical daily example is paracetamol in very young infants.

Last case I had was Dr prescribing Tramacet 3 x four times a day. On phoning she said as paracetamol content reduced she had increased dose to equivalent of 2 x four times a day standard paracetamol.

I said high dose probably off licence so she reduced and said next time would prescribe separately.
johnep

[admin]

Originally Posted by Zoggite

Is that a promise? exit 22a off the A55, turn left at the roundabout, then we're at the 2nd set of traffic lights!
how do you like your tea- milk and 2 sugars?

Don't need sugar - I'm sweet enough............

Ok, so today I looked out for dose changes - 327 scripts and 60 addicts, but I still kept an eye out. Had 9 dose changes all from the same surgery. Tried to ring on the first three but just could not get through to the Dr's - all in surgery and wouldn't take my calls. Friday, people need their drugs, all within licence limits, what do you do? I asked the receptionist to get back to me if any were errors - heard nothing. So that makes me a bad pharmacist I guess.

[Steve G]

Originally Posted by admin

Don't need sugar - I'm sweet enough............

Ok, so today I looked out for dose changes - 327 scripts and 60 addicts, but I still kept an eye out. Had 9 dose changes all from the same surgery. Tried to ring on the first three but just could not get through to the Dr's - all in surgery and wouldn't take my calls. Friday, people need their drugs, all within licence limits, what do you do? I asked the receptionist to get back to me if any were errors - heard nothing. So that makes me a bad pharmacist I guess.

Most of the time you don't need to phone the surgery because the patient knows what's going on - they've had their lisinopril dose increased because their BP isn't quite on target. If however you had a patient whose methotrexate dose had gone from say 5mg per week to 20mg per week, and the patient doesn't have a clue, that's when you phone the GP to check.

[admin]

Originally Posted by Steve G

Most of the time you don't need to phone the surgery because the patient knows what's going on - they've had their lisinopril dose increased because their BP isn't quite on target. If however you had a patient whose methotrexate dose had gone from say 5mg per week to 20mg per week, and the patient doesn't have a clue, that's when you phone the GP to check.

Sorry, I missed out that a few were deliveries, a couple were people picking up for relatives and the other couple didn't know the dose was changing.

Obviously if it was methotrexate I'd not dispense it. Did you read my post about the woman being prescribed an overdose of fexofenadine and the trouble that caused?

[Fattoo]

I think errors will always occur because we are humans. However, Our mistakes will be fatal because they are related to human health. We should try every possible procedure to prevent mistakes.

I made several mistakes during my practice. Everytime I made mistake, I feel depressed and hate my job. I cannot help myself with that. I get worried very much to the degree I do not want to dispense anymore in this day.

My first mistake is dispensing 5mg zestril instead of 10mg tablet during my training. I was afraid to death. I got the patient's phone number and tried to call him. But, I was not able to reach the patients. My collegues told me it is Ok. He used to take the medicines and he knows his medicine. In addition, I gave him lower dose.

My biggest mistake is when I was the boss in endocrine pharmacy and we mistake One-alpha capsules 0.25mcg with 1 mcg. The packs are exactly the same. I tried my best to correct such big mistake. I even went to an elderly patient home to give her the right concentration.

One pharmacy has a simple system to prevent errors. The prescriptions are checked by at least two pharmacist before they are dispensed. It is a good idea but it needs staff.

I also notice something. Physicians do not worry about their mistakes as we do, why? Pateints also think that we make mistakes but not the doctors, why?

[Cathedral]

My worst mistake was dispensing furosemidum instead of furaginum. It was a handwritten prescription... I managed to reach the patient before he had taken it.
Doctors don't care at all... One day a patient came to complain - for about two months he had been taking doxazosin 1mg instead of 4 mg because his doctor hadn't put a dose on the prescription. He thought it was my mistake. But after that he kept visiting the doctor - and the doctor made the same mistake two more times. Each time it was me to send back the patient to correct the dose.
Yesterday I had a prescription for "Cizertin" althuogh there is no such drug. It should be "Tisercin", but the doctor couldn't remember it so she wrote "whatever".
In Poland each prescriptionis checked after dispensing by another pharmacist which is good and helps to reveal mistakes quickly. We don't correct minor mistakes. We always try to contact when the patient is a child.