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  • Drug Errors

    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.
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  • #2
    Non CRC Cap

    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.
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    • #3
      Yes.If the woman's daughter didn't find this mistake,the results is terrible.
      mail: xiongliang0#gmail.com

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      • #4
        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

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        • #5
          Errors

          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
          Lively debate is encouraged but please respect the opinions and feelings of others.
          Please help keep the forum vibrant by spreading the work to friends and colleagues via word of mouth or social media.
          Thank you for contributing to this site.

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          • #6
            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

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            • #7
              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.

              Comment


              • #8
                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.
                Lively debate is encouraged but please respect the opinions and feelings of others.
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                • #9
                  Zoton/Zispin mix up

                  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.
                  Lively debate is encouraged but please respect the opinions and feelings of others.
                  Please help keep the forum vibrant by spreading the work to friends and colleagues via word of mouth or social media.
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                  • #10
                    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
                    Kemzo the pharmacist forumly known as kemzero

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                    • #11
                      Originally posted by admin
                      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.
                      Yeah, the delivery driver picked it up to check that we had actually made an error, and then I delivered the correct medication on my way home as its just round the corner from me. She took half a tablet three times, but no harm done. The patient was fine and happy enough when I took the correct medication round.

                      Kemzero: yes, it was recorded with copies sent to head office and superintendent.

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                      • #12
                        Originally posted by 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
                        I honestly don't know. I know he is an excellent pharmacist, but with the blame culture we live in he maybe decided against it.
                        Lively debate is encouraged but please respect the opinions and feelings of others.
                        Please help keep the forum vibrant by spreading the work to friends and colleagues via word of mouth or social media.
                        Thank you for contributing to this site.

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                        • #13
                          Drug Errors- High court ruling 11/nov/2006

                          Dear colleagues

                          The judge in the recent Dexamethasone case ruled in favour of the plaintiff, unfortunately lloydspharmacy might be lumbered with a £5m compensation bill ....they are planning to appeal .
                          Technically the pharmacist dispensed what the Doc prescribed but the judge ruled that he did not follow company protocol (check dose suitability etc) this indicates that pharmacists have a duty of care towards patients ( which I am sure we all know) but to what extend , it was not a dispensing error , it was a clinical error which the pharmacist should have conveyed to the prescriber (judge's ruling) .....the million dollar question is how would this affect remote supervision and future community pharmacy practice if our necks are on the line for both clinical & dispensing errors ? By the way there is another similar case in the pipeline ....
                          Kemzo the pharmacist forumly known as kemzero

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                          • #14
                            Originally posted by kemzero View Post
                            Dear colleagues

                            The judge in the recent Dexamethasone case ruled in favour of the plaintiff, unfortunately lloydspharmacy might be lumbered with a £5m compensation bill ....they are planning to appeal .
                            Technically the pharmacist dispensed what the Doc prescribed but the judge ruled that he did not follow company protocol (check dose suitability etc) this indicates that pharmacists have a duty of care towards patients ( which I am sure we all know) but to what extend , it was not a dispensing error , it was a clinical error which the pharmacist should have conveyed to the prescriber (judge's ruling) .....the million dollar question is how would this affect remote supervision and future community pharmacy practice if our necks are on the line for both clinical & dispensing errors ? By the way there is another similar case in the pipeline ....
                            Yes, it was a clinical error, but something I hadn't noticed before was that this patient had 0.5mg dexamethasone dispensed seven times before at that pharmacy. Given that history, I'd at least have a quick chat with the patient.
                            http://www.pjonline.com/Editorial/20...roiderror.html

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                            • #15
                              Originally posted by Steve G View Post
                              Yes, it was a clinical error, but something I hadn't noticed before was that this patient had 0.5mg dexamethasone dispensed seven times before at that pharmacy. Given that history, I'd at least have a quick chat with the patient.
                              http://www.pjonline.com/Editorial/20...roiderror.html
                              That would require the pharmacist to be the one doing the labelling and for the pharmacist to be labelling from the repeat screen.
                              Now the idea of a Lloyds pharmacist doing a MUR while the prescription was prepared and checking it at the end does not seem to be beyond imagination.
                              I am not aware of anything in the Lloyds proceedure manual that insists that scripts be labelled from the repeat sceen - or that the pharmacist does the labelling - but I might be mistaken.

                              Jeff

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