Near Miss at Prescribing Stage - What Would You do?

Nurses Safety

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I came across a near miss, but it was not in the context of my own employment. A relative of mine was recently discharged from hospital. On discharge she was given a script for her meds. However before discharge, the nursing staff or the doctor did not explain to her that there was some changes in the dosage to some of her existing meds, or that she was being prescribed some new meds.

On going through the script, before I headed to get it dispensed, I noticed that there was a serious error in the dosage of one of the anti-hypertensive's meds that she was being prescribed. It must be said that the doctor didn't pick up on incorrect dosage subsequently, as it also appeared on the discharge letter, which was dictated one day post discharge. Thankfully, there was no harm done, but having said that, there was the real potential for harm. Through a bit of digging, I also found out that the doctor only graduated med school over a month ago. What would you do, would you report this near miss to the hospital?

Specializes in Clinical Research, Outpt Women's Health.

But my point is that the pharmacist most likely would have caught it if you hadn't amazed the world with your incredible find other peoples mistake super duper skills.....:lol2:

Ok, I know that sounds sarcastic, and i am really not meaning to be a total dog, but I get really tired of the perception that health care workers could possibly not make some mistakes, and the fact that they often get reamed and/or worse when they do despite the circumstances such as short staffing and long hours that set them up for it.

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

It doesn't sound like anything other than a one-off - at the teaching hospitals I worked at they review and discuss their patients later in the day rather than work on the buddy system where the attending would actually watch the intern write the script out.

I don't tink it being 2011 has anything to do with this at all. I caught people writing for too many leeches all the time! (sorry :)) Why not write the intern a note or give her a call to let her know? I'm certain she is very astute and will appreciate that approach.

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I mean how bad of an error are we talking about? Was this HCTZ 50mg instead of 25 (ie no big deal)?

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Specializes in Oncology; medical specialty website.
I would let the pharmacist contact him and get the correction. That is part of their job.

To err is human and most likely it would have been caught by the pharmacy. Wow, hope y'all jump down my hiney this fast if I ever make a mistake......:lol2:

I have to ask, what is up with all this "Should I report him/her?" When did nurses get so trigger-happy?

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Specializes in Oncology; medical specialty website.
This should not be a theory/practice gap anywhere. I know in our ED if we have a resident in the last month of his/her training (i.e. less than a month from practicing on their own), the attending must see each pt the resident sees and must cosign everything the resident does (usually after the fact). If the facility is allowing intens with just one month experience as an MD/DO practice on their own with no supervision, then this must go up the ladder--beyond the hospital if necessary.

This is an absolutely unreasonable posture to take.

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Specializes in m/s.

are we sure this isn't troll fodder?

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Specializes in PICU, Sedation/Radiology, PACU.

Wrong thread. Sorry.

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Specializes in ICU, Telemetry.

I am allergic to codeine -- anaphylaxis -- and tell both my doc and my pharmacy every time I move or change docs/pharmacies. I have been prescribed something with codeine in it from every doc I've had, and the pharmacies didn't catch it, either -- I caught it once when I was about 10 seconds away from taking some cough syrup that would have had me blue and very, very cough free.

Everyone makes mistakes except people who don't do anything. I didn't sue or report anyone, just mentioned it the next time I saw the doc or got a refill.

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Specializes in Emergency, Telemetry, Transplant.
This is an absolutely unreasonable posture to take.

So if I or a loved one is being treated by an intern with no apparent input from an experienced physician, it is unreasonable to demand that that experienced physican steps in an shows me that he/she is taking role in my care, rather that just leaving me to the doctor with 1 mo experience? I am all for residents, and they need to learn, but they need guidance in that learning process. I just want to make sure attendings are part of that process.

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It was discussed with the hospital, and on their advice, it was formally reported to risk management. Matter closed:).

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