Previously published in Patient Safety & Quality Healthcare
Medication errors can result in significant morbidity and mortality and more costly care. Look-alike drug names that contribute to wrong drug errors are pervasive. These errors happen in various ways; for example:
Prophylactic antibiotic coverage with penicillin 500mg oral tablets four times a day was ordered for a 43-year woman in intensive care with severe mitral and tricuspid valve regurgitation and an incidental jaw fracture who was scheduled for a surgical valve repair. On the second day of antibiotic therapy, a nurse compared the drug she was to administer with the medication administration record and discovered the patient was receiving penicillamine instead of penicillin. Further evaluation revealed the staff member who entered the order into the pharmacy computer system typed in “PENIC” and had received a drop-down box that displayed all the formulations starting with “PENIC.” The pharmacist entering the order unintentionally selected penicillamine instead of penicillin (Flynn, 2006).
A 40-year-old woman with bipolar disorder (on trazodone) received handwritten prescriptions for Zyrtec® and Atarax® to treat a new episode of urticaria. The pharmacist dispensed Zyprexa® instead of Zyrtec. It was not until a 2-week follow-up appointment that the error was identified (Cohen, 2003).
Epinephrine and ephedrine were available on override in adjacent sections of an automated dispensing cabinet drawer. When a physician requested a dose of ephedrine for a patient in labor, a nurse hurriedly drew up a dose of epinephrine and handed it to the primary nurse, who administered the dose. The patient experienced chest pain and a period of hypertension before the baby was born, however, there were no long term effects for the mother or newborn (ISMP Medication Error Reporting System, n.d.).
To read the rest of the article please visit Patient Safety & Quality Healthcare
No comments:
Post a Comment