Has this ever happened to anyone? A med error caused my gram to be hospitalized and we are lucky!
Well today I ran to get my gram's Norvasc filled. They fill it with generic- No big deal Right? Well I get to her house (she is on 4 meds total- not too hard to keep track of).... I get back and am organizing her pill box and notice that she has it all screwed up..... Trying to sort through her meds I realize the Norvasc I just filled has the SAME exact pills as the Monopril I filled on 3/14/07. ***? I am thinking that the pharmacy made a mistake TODAY since it has a M on it and matches the other bottle, etc. i then realize the meds in the monopril bottle from last month are actually generic Norvasc and that the script from today is correct. She had been taking double norvasc and NO monopril for a month! It was not caught sooner as she had been taking the name brands which are not even shaped or colored the same.
The pharm error was made on 3/14/07. she was hospitalized 3/15/07 for bradcardia and afib, irreg heartbeat. hmmmmm any connection ya think?!?!
Now gram is 86 but me as an average functioning nursing student it was sooo confusing to me I can't imagine that she would have ever figured it out. The hospital did not even catch it, as I had brought every pill bottle in.
I finally just filled her weekly pill box and took home the rest of the bottles- I will fill them weekly for her, although sad to say I trust her more than I trust the pharmacy right about now.
I guess the moral of the story is to be very very careful when working with seniors on meds and try to be consistent with the brands, manufacturer, etc. to prevent errors from happening.
I once had both of my two prescriptions refilled at the same time, one was synthroid and one was benicar. When I got home, the meds were in the wrong bottles. It took a minute even for me to realize it because I had just started taking the benicar. When I opened the benicar bottle, I thought, "That's funny, this benicar looks just like my synthroid tablets." Then I realized what had happened and there was no harm done. But for some little gramma, it may not have been had such a good outcome.
Another time I caught a really major one by our hospital pharmacy. I was working in the ER and a young lady came in with an infected tonsil. The MD ordered clindamycin IV, which we usually just hang as a gravity drip over 30 minutes. The med came down from pharmacy, and I checked the label, which read "clindamycin 300 mg give IV over 30 minutes". Luckily for the patient, it was mixed from one of those vials that screw into the solution set, and when I checked THAT vial, it was actually DILTIAZEM 250mg!!!! My coworker said my face got beet red when I showed it to her. Can you imagine running that in over 30 minutes? Even a healthy patient like this one would probably not have survived.
Needless to say, it wasn't given and an incident report was generated. We all learned to check and double check every med you give, even if pharmacy mixes it for you. You just never know.
Keshet
13 Posts
I once had both of my two prescriptions refilled at the same time, one was synthroid and one was benicar. When I got home, the meds were in the wrong bottles. It took a minute even for me to realize it because I had just started taking the benicar. When I opened the benicar bottle, I thought, "That's funny, this benicar looks just like my synthroid tablets." Then I realized what had happened and there was no harm done. But for some little gramma, it may not have been had such a good outcome.
Another time I caught a really major one by our hospital pharmacy. I was working in the ER and a young lady came in with an infected tonsil. The MD ordered clindamycin IV, which we usually just hang as a gravity drip over 30 minutes. The med came down from pharmacy, and I checked the label, which read "clindamycin 300 mg give IV over 30 minutes". Luckily for the patient, it was mixed from one of those vials that screw into the solution set, and when I checked THAT vial, it was actually DILTIAZEM 250mg!!!! My coworker said my face got beet red when I showed it to her. Can you imagine running that in over 30 minutes? Even a healthy patient like this one would probably not have survived.
Needless to say, it wasn't given and an incident report was generated. We all learned to check and double check every med you give, even if pharmacy mixes it for you. You just never know.