mmus

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

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.

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.

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?