The following is abridged from ISMP MEDICATION SAFETY
ALERT.
Published by the Institute for Safe Medication Practices; Web site: www.ismp.org.
Reprinted with permission.
A 79-year old hospitalized woman accidentally received seven doses of the oral diabetes medication glyburide, which was intended for another patient. A nurse took a verbal order for glyburide, 10mg orally BID, for a diabetic patient, and correctly transcribed it onto an order form. But then this form was stamped (Addressograph) with the name and data of the wrong patient.
Pharmacy received a copy of the order, and dispensed the medication. Because the 79-year old woman was not diabetic, she eventually developed symptoms of hypoglycemia, and had to be transferred to ICU, where it was found her blood glucose level was 10 mg/dL. Fortunately, the patient recovered without permanent harm.
To prevent such errors, some pharmacies forbid dispensing dispensing insulin or oral hypoglycemic drugs unless the pharmacist confirms the patient is diabetic, is on TPN (IV feeding) and not tolerating the glucose load, or has some other therapeutic reason for the medication. If there is no reliable way to obtain this information in a timely manner through routine communication, the pharmacist must specifically seek out this information, and intervene, if the therapy does not appear to be indicated.
It is not a case of ignorance, of failure to access drug information. The problem is one of human confusion and inevitable error; and, as in so much of human endeavor, the answer is in vigilance -- in checking, cross-checking, and checking again...