check those blister packs

[makes needs known]

I found a patient's blister pack for gabapentin (neurontin) 600mg filled with gemfibrzil (lopid) 600mg, dispensed by our pharmacy. The label on the front said gabapentin 600mg, the individual packs on the backside of pack said gemfibrozil 600mg. I called the pharmacy to have them identify the pill. They admitted a mistake had been made. Sound alike and look alike drugs.

[sethmctenn]

When I worked in pharmacy, we made a lot of our own unit dose packaging for LTC facility use. There is potential for error there just like everywhere else. We had a policy that two people, including at least one pharmacist, had to check them. Some pharmacy departments are lazy about repacking and let tech check tech.

Good save on that one! Hopefully the pharmacy appreciated your thoroughness.

[scoochy]

Blister packs are only as good as the people packing them. At the LTC facility in which I work, the RN supervisor as well as a second nurse must sign in all narcotic deliveries. There have been numerous occasions in which either a "blister was empty," or there were 2 doses in one "blister." This system helps to prevent some of the narcotic count discrepancies.

[redtshirt]

At the end of a late shift we recieved our drug order for the day. Went to give the medication to my patient that had just come up, box was plain white with a sticker on it containing all the right information. Opened box looked at blister pack it was a strip of an entierly different drug which i remember was a sleeping tablet. It was my final year of training, i was proud of my call, and i submitted a medication error report. Only to get given out to by the manager the next day for doing so because it made work for her.

I was glad my patient didnt sleep for days because i was thorough in my medication checking. Slips are easy to make.