Medication Error: Wrong Dose, Wrong Patient!

Medication Errors: Don’t Let This Happen to You!
Dr. Mike shares a story from the news or one of his readers about a medication error.

Earlier this week, my wife had some minor surgery at an ambulatory surgery center at one of the most respected teaching hospitals in the Northeast. While waiting for her to recover, I watched the following set of medication errors take place.

Two men – both named John – were having surgery, one on his shoulder (John A), and the other on his hand (John B). While in the recovery room, each wife was given a prescription to take to the surgery center’s pharmacy.

Error #1: The doctor for John A wrote a prescription for a narcotic painkiller, but indicated a dose that is not available.

Error #2: The pharmacy gave the prescription back to John’s wife to bring to the physician to rewrite it for the correct dose. However, the pharmacy clerk gave the prescription to John B’s wife instead of John A’s wife!

The outcome: When John B’s wife returned to the surgical center, the nurse immediately saw the mix-up and called the pharmacy, which had already given John B’s medicine to John A’s wife. It took about 20 minutes to get the wives together and figure out who was supposed to get which medication.

In the meantime, John A’s doctor had left the facility and no one was available to rewrite the prescription for the correct dose. Almost an hour later, when my wife and I left, John A’s doctor had still not answered his page or cell phone. Hopefully, John A has his medication and is healing comfortably.

You can be sure that I carefully checked my wife’s medication before we left for home.

Let Dr. Mike know if you have a story to share about your medication. Leave a comment below or post in the Medication Forum.

..............................................
Photo © khuonghoang/istockphoto.com