Near Miss at Prescribing Stage - What Would You do?

[mmus]

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?

[Isabelle49]

I think I would call the prescribing doc and let him know that you caught the 'miss' and what dose it should have been, so he can adjust his records also. Unfortunately he's human and knowing what happened will help him grow and make him more attentive. Am sure he'll appreciate your call.

[Double-Helix, BSN, RN]

If he just graduated med school a month ago then he is likely still a resident or even an intern and should be being supervised by an attending physician. It's not the job of the family member to check dosages and catch med errors. Fortunately, you did, but a family with less knowledge of medication would not have, and the outcome could have been very bad. Since the patient was sent home with the script and the error was caught by family I doubt that the hospital will consider it a near miss, but a med error.

This should be reported to the hospital and the physician. I would call physician and explain the error to him, as well as the attending on the unit. Also call the floor where your family member was discharged and ask to speak with the nurse manager on the floor and tell her what happened. Since the nurses did not catch the error either, they should know about it. You also might want to talk to the facility's risk management officer to make sure there was follow up.

I'm glad you payed attention! Your relative is lucky to have you!

[CrunchRN, ADN, RN]

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......

[tyvin, BSN, RN]

Give the guy a break ... call him and tell him so he knows; it's called experience. It would have been caught at the pharmacy.

[mmus]

The doctor is an intern and in theory she is suppose to be supervised...but that's another one of those theory/practice gaps where I live:eek:!

Luckily, I did notice the error and I ended up querying the dosage with her own family doctor. He wrote another script with the correct dosage. The family doctor didn't report it. Unfortunately my relative had to be re-admitted through the emergency dept. the following morning, and later that day, the discharge letter was on the hospital information system and it still had the incorrect dosage. That letter was then forwarded onto her family practitioner later on. The pharmacist is out of the equation.

My line of thought is about risk management and also wider patient safety, and whether this may be symptomatic of a wider possible problem that may or may not exist. Where I live these errors are also seen as a near miss, and they are collated as part of official stats.

If the prescribing doctor is made aware of this, maybe she can learn from this experience, and pay more attention the next time she's writing scripts. Without getting on my soapbox, it also highlights the need for the proper supervision of newly qualified doctors.

[CrunchRN, ADN, RN]

I am really sorry, but the way the system is set up the pharmacist must fill the RX and so would be "in the equation".

I am all for educating the person about their mistake, but it feels to me like there is more to your agenda than a judicious attempt to help educate, but rather than the desire to show some crummy little know it all new MD that the nurse is mightier than the sword..........

Seriously, there is a way to do this that does not reek of neener neener I am better than you.

I am sorry if I am wrong, but to me that is how this whole thing reads and while I heartily endorse educating him about the error (as we all would need to be) so that is not repeated, a little sympathy and understanding would not be out of line. Maybe that doc was having a shift from hell. Nurses and all other health care professionals make plenty of mistakes too. And gleefully rubbing your/mine/their face in it is not helpful and prevents it from being a productive learning experience.

[Anna Flaxis, BSN, RN]

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.

Antihypertensive.

[Anna Flaxis, BSN, RN]

The doctor is an intern and in theory she is suppose to be supervised...but that's another one of those theory/practice gaps where I live:eek:!

Supposed.

Luckily, I did notice the error and I ended up querying the dosage with her own family doctor. He wrote another script with the correct dosage. The family doctor didn't report it. Unfortunately my relative had to be re-admitted through the emergency dept. the following morning, and later that day, the discharge letter was on the hospital information system and it still had the incorrect dosage. That letter was then forwarded onto her family practitioner later on. The pharmacist is out of the equation.

Readmitted. On to.

My line of thought is about risk management and also wider patient safety, and whether this may be symptomatic of a wider possible problem that may or may not exist. Where I live these errors are also seen as a near miss, and they are collated as part of official stats.

If the prescribing doctor is made aware of this, maybe she can learn from this experience, and pay more attention the next time she's writing scripts. Without getting on my soapbox, it also highlights the need for the proper supervision of newly qualified doctors.

The doctor made a mistake. The mistake was caught. No harm was done. Let it go.

[mmus]

The pharmacist would have been in the equation, if the original script was presented to the pharmacist for dispensing. However, it wasn't! Another script with the correct dosage was presented. Its not about getting something over on the doctor....but its quite funny that that kind of view exists in 2011. Patients should be able to trust what a doctor is prescribing is the correct dosage. Doesnt get any simpler than that.

[psu_213, BSN, RN]

The doctor is an intern and in theory she is suppose to be supervised...but that's another one of those theory/practice gaps where I live:eek:!

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.

[psu_213, BSN, RN]

The pharmacist would have been in the equation, if the original script was presented to the pharmacist for dispensing. However, it wasn't!

CrunchRN can correct me if I misrepresent them (sorry if I do)...but I think their point is the pharmacist would have been another check in this situation and would have been another chance to correct the error. Yes, the doctor made a bad mistake, but there is more to the situation than the error made by this intern (which, once again, illustrates why interns must be supervised...in theory and in practice).