Significant Adverse Drug Events
1. An 88-year-old female was prescribed 12 mcg fentanyl
patch but it was dispensed as 25 mcg fentanyl patch.
The patient complained of unwanted side effects such
as sweatiness, agitation, and respiratory depression. The
pharmacist did not catch the error and the nurse who applied
the patch did not catch the error. The pharmacy will
be more diligent when verifying prescriptions.
One patient was to receive Zostavax® and the
other was to get a Tdap vaccination. The Zostavax was
mistakenly diluted with the Tdap solution instead of the
Zostavax diluent. The pharmacist called both manufacturers.
The pharmacist was informed that since Tdap had no
preservatives, that the Zostavax should not be affected.
The pharmacist contacted the Centers for Disease Control
and Prevention (CDC). The CDC reiterated what
the manufacturer had stated and also suggested that the
pharmacist call Food and Drug Administration (FDA).
The pharmacist contacted FDA. FDA requested that the
pharmacist file a report to the Vaccine Adverse Event
Reporting System. The patient did not experience any
pain or unwarranted effect.
3. Patient filled a prescription for levothyroxine 75 mcg.
Prescription was dispensed with generic Lexapro®. The
patient did not take any of the generic Lexapro.
4. A 69-year-old male patient was prescribed amiloride 5 mg
tablets. Prescription was dispensed with amlodipine 5 mg.
The patient complained of lethargy, edema, and swelling
of the eyes. The error occurred during a telephone transfer
from another pharmacy. The receiving pharmacist said
that the pharmacist he was getting the transfer from said
amlodipine 5 mg. The pharmacist taking the transfer
did not reverify the correctness of the medication being
transferred. The pharmacy had a meeting to retrain all staff
on its policy for receiving transferred prescriptions, with
emphasis on trying to get prescription numbers, original
bottles, and repeating back information.
Patient was prescribed diazepam 10 mg; take one tablet
one hour prior to appointment. Prescription was dispensed
as diazepam 10 mg; take four tablets one hour prior to appointment.
Patient became very sleepy. Pharmacist states
that the directions were not checked. Pharmacist states
that during counseling, the amount of tablets to take was
not discussed. Pharmacist states that directions for use
should be discussed during counseling.
6. A 66-year-old male who had a stroke in the past and was
on warfarin fell and his broke arm. Patient was dispensed
indomethacin when apparently nothing was prescribed.
This was due to an error with the electronic prescribing
system. Pharmacist is unsure why this happened. The
pharmacy will try to determine if the error is with Surescripts.
In the future, the pharmacy will pay more attention
to the verification process. Also, more due diligence in
patient consultation.
7. A 48-year-old female was prescribed cephalexin 250
mg; take one capsule four times a day. Prescription was
dispensed cephalexin 250 mg; take one capsule daily.
Patient reports that her infection got worse. Patient’s prescriber
wrote a new prescription for a different antibiotic
(clindamycin). Pharmacist states that it was an inexperienced
technician entering the information. Pharmacist
reviewed the information too rapidly. The abbreviation
“Q6h” or “Q6” was misinterpreted as “QD.”
8. A 33-year-old female was prescribed Adderall® 10 mg for
diagnosis of adult attention deficit hyperactivity disorder.
Patient was dispensed amphetamine salt combo. Patient
felt nauseous and could not sleep. This is a recurrent
prescription for this particular patient and she only has
it filled at this pharmacy. The pharmacist stated that a
better job will be done to verify recurrent prescriptions,
especially if there is any ambiguity.
9. A 30-year-old male was prescribed lorazepam 1 mg for
anxiety. Patient was dispensed alprazolam 1 mg. The
patient reported having mild dizziness as a result. The
pharmacy had dispensed another patient’s medication to
this patient. The technician did not confirm the address
of the patient picking up the prescription. The pharmacist
stated that they were very busy at the time and many
patients were being attended to. Pharmacist states that
technicians must confirm patient address as required by
procedure. Pharmacist states that new technology now in
place should eliminate this type of event.
10. A 65-year-old female was prescribed trazodone 50 mg for
insomnia. Patient was dispensed tramadol 50 mg. Patient
felt lightheaded, dizzy, and nauseous. The pharmacy
technician typed in the prescription as tramadol 50 mg.
Verifying pharmacist also misinterpreted as tramadol 50
mg as well. The staff states that the error was due to unclear
handwriting of physician and multiple prescriptions
written on the same prescription blank. Pharmacist states
that checks and balances normally catch this type of error.
11. A pharmacy, which is usually staffed with three pharmacists
on certain days, had to work with only two
pharmacists on a busy Monday. During this extremely
busy time, a patient came in to the store and dropped off
a prescription for Endocet® 7.5/325. The pharmacist incorrectly
filled the prescription with Endocet 10/325. The
patient noticed the error prior to taking the medication
and notified the pharmacy. The patient refused to bring
the medication back. Patient has a history of narcotic
use. The pharmacist states that the error is due to being
understaffed. Pharmacist states that he will not leave on
a Monday if there are not enough pharmacists on staff.
12. A 59-year-old female with depression was prescribed citalopram.
Patient was dispensed losartan 100 mg. Patient
complained of headaches and anxiety. The pharmacist
missed the error on the double check. To prevent future
errors such as this one, the pharmacist will double check
contents in the prescription bottle with the contents from
the stock bottle.
13. A patient came into a pharmacy with eight new prescriptions
plus two refills. Both the pharmacist and the technician
were counting the medications in order to process
the large order. At some point during this filling process,
lamotrigine 200 mg was filled twice. This error was not
caught. Pharmacist says that the lamotrigine 200 mg looks
similar to the prescribed Topamax® 200 mg. Pharmacist
states that all vials should be opened. Pharmacist states
that you should check and match the contents of the vial
with the stock bottle.
Disclaimer: The suggestions are made by the pharmacist
submitting the Significant Adverse Drug Event Report. The
New Mexico Board of Pharmacy may not necessarily agree
with these suggestions.
quoted from here
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