From the Guidelines
This is a prescribing error that was caught before reaching the patient, specifically a "near miss" or "good catch" in medication safety terminology. The intern made a dosing error by writing 2000mg instead of the intended 500mg q6 hours, which represents a four-fold overdose. The pharmacist recognized this discrepancy and intervened by changing the order back to the correct dose, demonstrating the importance of the pharmacist's role in the medication verification process, as supported by the development of pharmaceutical care, which aims at ensuring optimal individual pharmacotherapy and appropriate and errorless drug handling 1. This scenario illustrates the effectiveness of having multiple healthcare professionals review medication orders as a safety mechanism.
Key Points
- The error occurred due to incidental distraction of attention, which can lead to suboptimal performance, especially in specialized activities such as checking and administering medicines 1.
- Involvement of clinical pharmacists in almost the entire medication process can reduce medication errors, which can be achieved through special medication ward rounds, the use of computer-assisted and barcode-controlled bedside dispensing, and an extra check whenever a pharmaceutical formulation is modified before administration 1.
- This type of error would be considered a potential adverse drug event (ADE) that was intercepted before reaching the patient.
- Prescribing errors, like the one in this scenario, are among the most common types of medication errors in healthcare settings, highlighting the need for robust medication safety systems and error prevention strategies.
From the Research
Error Type
- The type of error that occurs when an intern prescribes 2000mg of a medication every 6 hours (q6 hours), instead of the intended 500mg every 6 hours (q6 hours), is a prescribing error, specifically a dosage error 2, 3, 4.
- This error can be classified as a tenfold medication dose prescribing error, which is a well-recognized risk, particularly to patients 4.
Characteristics of the Error
- The error is an example of a knowledge-based error, where the intern lacks the knowledge to prescribe the correct dosage 2.
- The error can also be classified as an action-based error, where the intern takes the wrong action by prescribing the incorrect dosage 2.
- The error is potentially serious, as it can lead to harm to the patient, and it is important to detect and correct it to prevent adverse outcomes 3, 4, 5, 6.
Correction of the Error
- The pharmacist's correction of the error is an example of a mitigation strategy to prevent harm to the patient 3, 5.
- The correction of the error highlights the importance of having a system in place to detect and correct medication errors, such as pharmacist-led medication reconciliation and computerized physician order entry (CPOE) 3, 5.