What happened?
A pharmacy technician while taking medication orders over the phone made transcription error led to the death of a patient.
A female patient was hospitalized in US for fluid buildup in her lungs. While discharging a nurse at the hospital called in prescriptions for multiple medications to a local chain pharmacy. One of those orders was for a diuretic, metolazone.
The call was taken by a pharmacy technician who had no formal pharmacy training or education before becoming a pharmacy technician.
The pharmacy technician made numerous transcription errors, misspelling the names of several medications being ordered, misspelling the name of the nurse on the other end of the phone call, and recording an incorrect birth date for the patient, dosage of an inhaler being prescribed, with what she recorded being 10 times the correct dosage.
While dispensing the medication the approach used in the pharmacy was for the technician to look in the computer where the medications were arranged alphabetically by name. A drop-down menu would appear after the first 3 letters or so of the drug name that had been entered. The pharmacy technician entered m-e-t and a dosage strength of 2.5 mg which was selected methotrexate not metolazone.
As per methotrexate drug information and warnings one should take methotrexate exactly as it was prescribed. Methotrexate usually taken once or twice per week and not every day. There were incidents where some people died after taking methotrexate every day by accident and also patients with lung diseases were not advised to take methotrexate without physician approval.
Institute for Safe Medication Practices classifies methotrexate as a “high-alert” drug product and that many pharmacy computer systems include a “hard stop” that prevents printing a label indicating that it should be taken once per day.
The pharmacy staff member provided no further counseling or warning about the medication, even though the pharmacy manual of the chain specified that it “strongly recommends” that all patients with new prescriptions receive patient counseling, even if not required by state law.
Due to these multiple medication errors especially dispensing the wrong medicine caused death of patient.
Brief about dispensing errors:
Many prescription errors are made during the various phases of medication usage in the hospital environment; dispensation is one of the most sensitive phases of the process. Safe, organized, and effective dispensing systems are fundamental to ensure that drugs will be properly dispensed according to the prescription order forms, and to reduce the possibility of errors.
A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality
Categories of dispensing errors
- Dispensing with the wrong verbal information to the patient or representative
- Dispensing medicine for the wrong patient (or for the wrong ward)
- Dispensing the wrong medicine
- Dispensing the wrong drug strength
- Dispensing at the wrong time
- Dispensing the wrong quantity
- Dispensing the wrong dosage form
- Dispensing an expired or almost expired medicine
- Omission (i.e. failure to dispense)
- Dispensing a medicine of inferior quality (pharmaceutical companies)
- Dispensing an incorrectly compounded medicine (compounding in pharmacy)
- Dispensing with the wrong information on the label
- Incorrect patient name
- Incorrect drug name/strength/quantity/dosage form/expiry date
- Incorrect instruction (including incorrect dosage)
- Incorrect instruction (including incorrect dosage)
- Omission of additional warning(s)
Source of case: Pharmacy times
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