Medication/Pharmacy errors... - page 3

by ObtundedRN 4,681 Views | 25 Comments

So working in the hospital, as a nurse, one of our responsibilities is to be the very last check that a medication is appropriate and safe for the patient. I catch pharmacy errors on a regular (and too frequent) basis. Usually it... Read More


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    Quote from ObtundedRN
    So working in the hospital, as a nurse, one of our responsibilities is to be the very last check that a medication is appropriate and safe for the patient. I catch pharmacy errors on a regular (and too frequent) basis. Usually it is simple mistakes, caused by any number of contributing factors. But sometimes I find big errors, such as pharmacy putting 3 runs of IV KCL on the wrong patient's eMAR, who happens to have a K of 5.1!

    So if I find these errors in the hospital, it makes me question how often they happen outside of the hospital, where there is no nurse to help verify that the medication is correct.

    Today, one of these errors happened to my newborn nephew. The retail pharmacy entered the wrong dosage on the label... 5 times the intended dose. This dose was fortunately still a safe dose, even for a newborn. So luckily the MD says there should be no cause for concern. But just the fact that this kind of error occured and for a newborn that isn't even a month old yet, is scary.

    So please, everyone make sure you're verifing not only your patient's medications against the original MD order, but also make sure you and your family are getting the correct meds and doses from your own retail pharmacy.

    After my dad had a lap appy, I went to go get his pain meds. It was a drive-thru window, and the kid asked me dad's name and address, while looking at the bag/label. He told me the co-pay, which was not what dad had said. I pulled away from the window to check the med- it was for someone with the same name, a TOTALLY different address, and for asthma meds... I pulled back into line, and got up to the window and told the kid I got the wrong med. He had to get the manager (a pharmacist). My uncle almost went to get the meds- but I ended up going for some reason I don't remember (I was on home health at that time, and not supposed to be away from home, let alone running errands). Had I NOT gone, dad would have been breathing great, hurting a lot, and probably running around like a chicken on speed (he's not one to sit still on a good day...). His brother, and friend who had been alternating "dad watch" wouldn't have known the med wasn't for pain. Why would they?

    I've gotten ER tabs instead of regular release.
    psu_213 likes this.
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    I read a story last year that Walgreens make the most mistakes. I could not remember the percentage but I remember thinking it was a lot. I never trust anything...I check everything and I never ever administer a medication that I do not all about, including the dosage. Also if you know your patients and their medical hx yo can catch errors a bit easier..if the medication does make sense based on what you know about a patient..then question it?
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    Human beings make mistakes every day. Fortunately, individuals do not always make mistakes but sometime they do. Mistakes are not intentional but , realizing mistakes can be made, it is best to check and recheck.
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    Quote from NSGstudent12
    "They only appologized because they got caught"
    That does not mean they did it on purpose. I just means that the person who posted this suggested that they were not really sorry that they messed up. Quite a difference.
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    Quote from xtxrn
    After my dad had a lap appy, I went to go get his pain meds. It was a drive-thru window, and the kid asked me dad's name and address, while looking at the bag/label. He told me the co-pay, which was not what dad had said. I pulled away from the window to check the med- it was for someone with the same name, a TOTALLY different address, and for asthma meds... I pulled back into line, and got up to the window and told the kid I got the wrong med. He had to get the manager (a pharmacist). My uncle almost went to get the meds- but I ended up going for some reason I don't remember (I was on home health at that time, and not supposed to be away from home, let alone running errands). Had I NOT gone, dad would have been breathing great, hurting a lot, and probably running around like a chicken on speed (he's not one to sit still on a good day...). His brother, and friend who had been alternating "dad watch" wouldn't have known the med wasn't for pain. Why would they?
    How dare you blame the pharm tech for this?? It is clearly the fault of the person in that pharmacy who makes the biggest bucks! (Sarcasm icon goes here!)
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    at this level, i agree with the op we need to be more conscious when accepting medications from any given staff. on the other hand, just because they are a well-known pharmacies it doesn't excluded them from making errors. in addition, not that i'm trying defend the techs on any given pharmacy, however, i have noticed and been told by several pharmacist that when a tech fills a prescription they place it on a bin for the pharmacist to double check their work. therefore, is the pharmacist responsibility to correct any mishap prior reaching the pt. having said that, our every day individual are trusting their pharmacy to give them the correct dosage and medication that their doctor prescribe, in my opinion we can't expect our senior citizens that live alone to carry pdr to verify their meds. for any errors....just saying~


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