Drug Topics - September 1, 2008 - (Page 3) 3 REDUCING YOUR RISK Ken Baker, BS, PharmD, JD Analysis of a medication error I n this series we often look at lessons that can be learned from past errors. The first step in preventing future medication errors is understanding what caused the last one. We study our past failures because, if we do not change the actions that caused the mistake, we are bound to repeat it. Unless we make changes, our past will be but a prologue to our future. After reviewing all possible causes that may have contributed to an error, we look at each and ask if we can change that practice and to what extent changing it would affect future outcomes. Some things that may contribute to a mistake, such as the phone ringing at the wrong time, may not be something that can be easily remedied. We cannot stop the phone from ringing nor can we have it ring only when it is convenient for us. We may look for the causes of the error and will want to consider each, but we need to keep each in a perspective that includes other requirements. Consider the following example and ask which of the causes can If we do not change the actions that caused the mistake, we are bound to repeat it. be addressed and in what order: Julie was the pharmacist-in-charge at a relatively busy community pharmacy. On the day of the error, Julie was the only pharmacist on duty, and she had two technicians working with her. One of the technicians was certified and experienced; the other had worked in a pharmacy for only about two months. Julie took a new prescription by telephone for Catapres tts-1 transdermal patches and correctly entered “Sig: 1 q 7 days.” Julie placed the telephone prescription with other prescriptions to be filled that morning. The prescription was entered into the computer by the less experienced technician about 30 minutes later. She could not later recall why she typed the directions as “Apply one patch daily.” The patient picked up the filled prescription package later that afternoon. Because the prescription was a new medication for that patient, Julie counseled even though the patient said she was in a hurry and acted somewhat upset about having to wait while Julie came to the pick-up window. Julie cautioned Photography: Leukos / Getty Images
Table of Contents Feed for the Digital Edition of Drug Topics - September 1, 2008 Drug Topics - September 1, 2008 Analysis of a Medication Error Pilot Program Urges Safe Disposal of Medications Drug Topics - September 1, 2008 Drug Topics - September 1, 2008 - Drug Topics - September 1, 2008 (Page 1) Drug Topics - September 1, 2008 - Drug Topics - September 1, 2008 (Page 2) Drug Topics - September 1, 2008 - Analysis of a Medication Error (Page 3) Drug Topics - September 1, 2008 - Analysis of a Medication Error (Page 4) Drug Topics - September 1, 2008 - Pilot Program Urges Safe Disposal of Medications (Page 5)
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