Caught a major med error today!

[ProBeeRN]

So...I'm going about my business today in the world of homecare nursing, and I sit down to do my patient's insulin prefill for her. Her pharmacy (which shall remain nameless) sends her 3 boxes of her Novolin 70/30 vials every month but tapes them together under one label as one months worth of insulin. With me so far? Well today I opened the second box to get out the second vial as the first vial had been emptied and discarded last week. I'm about to start filling syringes when something stopped me- couldn't put my finger on it at first- then I realized that the insulin was clear. Wait a second! 70/30 is cloudy. Took a look at the label on the actual vial and sure enough--Nololin R. Ripped off the prescription label taping the three boxes together- sure enough, pharmacy delivered 1 box of 70/30 and 2 boxes of Novolin R, all under the script label of Novolin 70/30

Called her pharmacy, spoke to pharmacist. He's like "well that's not good". Anyway, I ran to the pharmacy (2 blocks over) and exchanged for the right insulin. All I could think of was...ok, if x amount of people die from med errors every year...this could have been one of them (her 70/30 dose is over 40 units BID-- imagine if she took 45 units of the Novolin R! :eek:)

[peas&carrots]

I work as a pharmacy tech and this doesn't surprise me. Most techs that fill medicine are hired with no experience and you don't have to have any schooling to be a tech. Retail pharmacies overwork their pharmacists and make them look at hundreds of scripts a day as fast as they can. No one is going to be perfect 100% and until quality becomes more important than money it will keep happening. Instead of hiring more pharmacists they just hire more inexperienced techs which are of course alot cheaper.

[mamamerlee, LPN]

This is so scary, the pt is so lucky for your 'eagle eyes'. What a great job you did, and now there needs to be follow through, we hope, at the pharmcy end.

So many of my pts have mail-ordered scripts that only get filled every 60 - 90 days, and this would have been a disaster.

GREAT CATCH !!!!

[clemmm78, RN]

Always go with your gut - there's a reason we feel not-right about things sometimes. Kudos. Nice to hear stories like this rather than "patient dies from med error."