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Oregon News: Adult Prescription Dispensed to Four Year Old
Published in the February 2009 Oregon State Board of Pharmacy Newsletter
A recent complaint that resulted in a case being presented to the Board illustrates a common break down in the most basic principles of pharmacy practice. Case No. 08-0400 begins with a mother presenting a prescription for an otic suspension for her four-year-old child and requesting a refill of her husband’s Ambien® prescription. The technician correctly entered the child’s prescription into the computer, entered a new prescription for Concerta® for another person under the child’s name and failed to enter the Ambien refill. The Concerta prescription had come from the same medical clinic and had been placed in the technician’s inbox. The pharmacist who checked the technician’s work did not detect the error.
Circumstances leading to the error include the fact that both new prescriptions, each intended for a different person, were put into an inbox together, and the fact that these were electronically generated prescriptions from the same clinic that were all identical in appearance. The breakdown began when the technician failed to read and enter the appropriate name on each prescription. It continued when the pharmacist failed to compare the name printed on each label with the name printed on each electronic prescriptions. The cascading error was completed when the pharmacist failed to perform the required drug utilization review and to provide adequate counseling, which should have led to the discovery that one adult prescription had been erroneously prepared and labeled for a child and was bagged for and dispensed to another adult. No injury resulted to either the child or his father since the father discovered the error at home before any doses were taken.
What can be learned from this case? It is this. There is no substitute for vigilance. There is no substitute for dispensing procedures that focus attention on these basics. Remember to:
- read the patient’s name;
- compare the label with the prescription;
- perform your DUR (review the appropriateness of each prescription for each patient);
- do your counseling; and
-
do not let this happen to you or one of your patients!
