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US Pharm. 2008;33(7):64.
A patient's father arrived at
a community pharmacy to pick up an antibiotic for his child (amoxicillin
suspension 250 mg/5 mL). However, unmixed amoxicillin powder was dispensed.
When he got home, the father measured 9 mL of powder, not 9 mL of liquid as
intended by the instructions on the pharmacy-generated label. After
administering the powder to his child, the patient's father thought it was
unusual that it was a powder and not a liquid medication, so he called the
pharmacy. It was then discovered that the patient received 9 g of amoxicillin
in one dose instead of the intended 450 mg.
The pharmacy where this event
occurred uses a process to prepare and dispense reconstituted medications that
is followed in many pharmacies across the country. The antibiotic is pulled
from the shelf and the pharmacy-generated label is affixed. The pharmacist
then verifies the prescription and medication and bags the medication with a
"mix card" that informs the clerk that the medication requires mixing. The
medication is then left in the "will call" area until the patient comes to
pick it up. Once the patient arrives at the pharmacy, the medication is
reconstituted and dispensed. However, on the day of this event, a new
pharmacist neglected to bag the prescription with the mix card. The clerk that
dispensed the medication was also a new employee and not familiar with the mix
card procedure. The clerk gave the unmixed medication to the patient's father
who had come to pick up the amoxicillin prescription. It appears from the
report that no pharmacist consultation occurred.
The pharmacist who reported
the event discussed this medication error with a few of his colleagues. The
response he received was very interesting and probably not all that uncommon.
The majority stated they had witnessed this type of medication error before or
were aware of it occurring with some regularity. However, the pharmacists were
not really concerned because it seemed that the error was easily identifiable
by the patient, and once identified, the patient would generally return to the
pharmacy. The pharmacists also commented that the reason the error is not
generally reported is that the situation is typically remedied before exposure
and is thus regarded as a near miss. Unfortunately, in this particular
situation that was not the case. (Please note that the Institute for Safe
Medication Practices does not agree with the way of thinking expressed by the
pharmacists surveyed above.)
Safe Practice
Recommendations
Merely relying on a
reminder placed on or with the prescription bag is not enough. A near miss
should be clear evidence that a serious event could occur. In order to
minimize the likelihood of errors, consider the following:
• Evaluate your
error-reporting systems for sharing near misses.
• Consider
placing new prescriptions for oral liquid medications, especially those that
need to be reconstituted, in a separate area away from other prescriptions
waiting to be picked up. Mark the area as "not to be dispensed without
speaking to the pharmacist." This may help remind staff that the product needs
to be mixed and that a pharmacist should review directions with the patient or
caregiver.
• Review the
label and directions for use with the patient.
• Ensure
that oral syringes (without caps) or other appropriate measuring devices are
readily available with the product or can be purchased at your practice site.
• Provide
education to patients and caregivers regarding proper use of the measuring
device.
• Demonstrate how
to measure and administer the dose and inform patients how to clean the
device, if it is to be reused.
In the case discussed earlier,
effective counseling would likely have stopped this error from reaching the
child.
To comment on this article, contact rdavidson@jobson.com.
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