Tuesday, June 14, 2011

Preventing The Perfect Rx Storm

Pharmacists, doctors, and patients need to work in tandem to help prevent the perfect storm from forming, which could lead to a continuing medication error.

ABC-15 News in Phoenix reports on a recent prescription error in which a patient received 50 mcg of liothyronine instead of the prescribed 5 mcg dose. The unfortunate young lady in this incident continued taking the misfill for months, and experienced all of the adverse effects one would expect from receiving 10 times the prescribed dose of her thyroid medication.


The perfect storm in which I'm referring happens when all of the following occur together -

1. A prescription order is entered incorrectly and a prospective DUR fails to catch it.
2. The pharmacist doesn't counsel the patient at the time of dispensing a new prescription.
3. The patient doesn't take the initiative to speak up to prevent errors.
4. The provider doesn't review the patient's prescription medications with each visit.

Of course, I don't know all of the sources that led to this error, and while not attempting to assess cause or blame, it seems to me that all four of these contributing factors occurred in order of succession, which may have allowed this incident to continue for so long. Any interruption in that perfect storm may have prevented the error from happening or continuing.

According to the video, the Arizona Board of Pharmacy is still investigating this incident. If you'd like to know the results of the investigation, who was involved, including any possible disciplinary actions, the board posts their meeting notices and meeting minutes online.

1 comment:

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