Drug Errors

[admin]

Today a woman brought back a packet of atenolol, that was labelled thyroxine. The makes/packs in the pharmacy I was working in were not the same, so I am unsure how this happened (it happened a few days ago through another pharmacist).

Luckily the woman's daughter had spotted the error so no harm was done. The only similiar thing was the atenolol was 50mg and the thyroxine was 50mcg, so I guess the "50" was seen.

[admin]

A couple of weeks ago a parent came into the pharmacy and told me two days previously her child had been prescribed paracetamol and amoxicillin. She had put the penicillin in the fridge. The top on the penicillin was not a child resistant cap, and the child had gone into the fridge and drank the whole bottle.

This had led to a few hours in the local A @ E department, and a child with diarrhoea and vomiting for the night.

The penicillin did not come with a CRC and unfortnately the original cap was used, which enabled the child to open the bottle and drink the contents. Obviously if this had been the paracetamol the consequences could have been a lot more serious.

I alerted the pharmacist who had been on duty that day, and used the correct error reporting procedures for the store.

[xiongliang0]

Yes.If the woman's daughter didn't find this mistake,the results is terrible.

[Jeff]

Originally Posted by admin

A couple of weeks ago a parent came into the pharmacy and told me two days previously her child had been prescribed paracetamol and amoxicillin. She had put the penicillin in the fridge. The top on the penicillin was not a child resistant cap, and the child had gone into the fridge and drank the whole bottle.

This had led to a few hours in the local A @ E department, and a child with diarrhoea and vomiting for the night.

The penicillin did not come with a CRC and unfortnately the original cap was used, which enabled the child to open the bottle and drink the contents. Obviously if this had been the paracetamol the consequences could have been a lot more serious.

I alerted the pharmacist who had been on duty that day, and used the correct error reporting procedures for the store.

Unfortunately the result is likely to be
A) The SOP already states that CRC caps should be used
B) the above will be added to the SOP

Reporting directly to the Patient Safety lot might put pressure on the store to purchase (and manufacturers to market) liquid antibiotics with CRC's as standard.

Jeff

[admin]

Hi everyone

I made a couple of errors myself last week. Fortunately they weren't serious - just caps for tabs, that sort of thing.

This seems to happen to me when the workload is really high - going for a target set at over 1000 items for the day last week. My friend reckons it's the other way round - you make errors when you have too much spare time, and your mind is not on the job all day.

I think she needs to come to some of the shops I work at, and she's wrong.

What do others think on this ?

Thanks

[Jeff]

Originally Posted by admin

Hi everyone

This seems to happen to me when the workload is really high - going for a target set at over 1000 items for the day last week. My friend reckons it's the other way round - you make errors when you have too much spare time, and your mind is not on the job all day.

I think she needs to come to some of the shops I work at, and she's wrong.

What do others think on this ?

Thanks

At the end of a rush - when I suddenly have some time and start to think about nipping out for a smoke.

Jeff

[Steve G]

just found out I made an error the other week; zoton fastabs 15mg given instead of zispin soltabs 15mg. This was for a delivery patient in one of those places where they rush around to get the deliveries done for the driver to take out, so that may have contributed.

[admin]

Originally Posted by Steve G

just found out I made an error the other week; zoton fastabs 15mg given instead of zispin soltabs 15mg. This was for a delivery patient in one of those places where they rush around to get the deliveries done for the driver to take out, so that may have contributed.

It's done so easy when you're rushing isn't it. I trust you got it back and changed it? At least no harm would have probably been done if they had taken any. The problem is that with these "no win no fee" lawyers everywhere, people too often instantly see this sort of thing as easy money. They'll try to wreck your life, all for a few quid. It's a sad state of affairs.

[admin]

Zoton/Zispin

My friend told me he had recently dispensed Zoton instead of Zispin (30mg). He gave Zoton fast tabs 30mg. No harm was done, and the drug was swapped.

[kemzero]

Hope it was logged on the clinical governace sheet and steps have been taken to ensure it doesn't happen again..... ouch sorry if i sound like the pharmacy police