Medication errors
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Prescription: Amoxicillin 875 mg BID for 10 days
Label: Amoxicillin 500 mg BID for 10 days
What’s the error?
What is wrong dosage given
Rx: Fluticasone nasal spray, 2 sprays each nostril once daily
Bottle contains: 120 sprays
Question: What is the day supply?
What is 30 days
Rx: Ciprofloxacin 0.3% eye drops
Sig: Instill 2 drops in each eye QID
Dispensed: 10 mL bottle
Question: What is the estimated day supply?
What is 12 days
John Smith DOB 01/02/1980
Jon Smythe DOB 01/02/1981
What is the error?
What is wrong patient
Rx: Lamotrigine ODT 25 mg
Filled as: Lamotrigine 25 mg tablet
What is wrong dosage form
Rx: Hydrocortisone cream, apply to rash TID
Patient reports using 1.5g per application
Question: How much cream is needed for 14 days of use?
What is 63 days
Rx: Prednisolone acetate eye drops
Sig: Instill 1 drop in each eye TID
Dispensed: 15 mL bottle
Question: Estimate the day supply.
What is 50 days
Rx says: “1 tab po qid x 7d”
Transcribed as: “1 tab po qod x 7d”
What is the error
What is wrong SIG interpretation
Scenario: A technician is texting while verifying the NDC on a stock bottle and selects the wrong strength.
Question: What caused this error? How could have this been prevented
What is being distracted and being on the phone?
Rx: Clotrimazole cream, apply to feet BID x 4 weeks
Estimated use: 2g per application
Question: How many grams are needed in total?
what is 112G
Rx: Ciprodex ear drops
Sig: Instill 4 drops in left ear QID
Dispensed: 7.5 mL bottle
Question: What is the estimated day supply?
What is a 9 days supply
Rx: Promethazine 25mg suppository q6h prn nausea
Filled as: Promethazine tablet 25mg
What is wrong dosage form given
Scenario: A technician working a 12-hour shift mistakenly types 100 mcg instead of 10 mcg for a fentanyl patch.
Question: How does fatigue contribute to errors? What workplace practices can help reduce these mistakes?
What is brain being too tired to focus on hard to keep focus. ensuring proper breaks are taken.
Rx: Albuterol inhaler, 2 puffs every 6 hours as needed
Inhaler contains: 200 puffs
What is the max dose daily?
What is 8 puffs per day
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Rx Intended: Clonidine 0.1 mg
Filled as: Klonopin 0.5 mg
What is wrong medication selected LASA drug
Scenario: A technician is working in a noisy, crowded pharmacy. The phone is ringing, two patients are waiting, and another staff member is asking for help.
Error: The technician grabs the wrong bottle and labels metformin as metronidazole.
Question: What environmental factors contributed to this error? How could it have been prevented?
What is the excessive noise, workload on staff, divided attention.
Prescription:
Apply thin layer of triamcinolone cream to arms, legs, and back once daily for 21 days.
Dispensed: 60g tube
Estimate the day supply based on 1g per body part rule.
What is 12 days
Rx: Tobramycin-dexamethasone eye drops
Sig: 2 drops in both eyes every 2 hours (while awake)
Dispensed: 5 mL bottle
Question: What is the estimated day supply?
What is 3 day supply