Medication Safety
Institute for Safe Medication Practices, Horsham, PA
Recently, a patient discovered an error during patient counseling. The patient had been taking lisinopril 30 mg, one tablet by mouth daily. Due to insurance coverage, the prescription was typically filled for a 30-day supply. However, the patient’s prescription drug coverage changed, and they requested the prescriber write a prescription for a 90-day supply.
When the prescriber wrote the new prescription, they inadvertently changed the directions to indicate that the patient should take three 30-mg tablets daily, which would result in the patient taking 90 mg of lisinopril daily instead of 30 mg, exceeding the maximum daily dose. The prescription did correctly indicate that the pharmacy should dispense a 90-day supply.
Despite the significant increase in the prescribed dose, the new prescription was filled. Because of the change in dose, the prescription was marked for mandatory patient counseling. During counseling, the patient confirmed that the prescription had not changed, and it was just meant to be a 90-day supply. However, rather than clarify and change the order with the prescriber, the pharmacist sold the incorrect prescription to the patient and informed them to follow up with their doctor for clarification. The patient received 270 tablets, rather than 90 tablets, along with the incorrect instructions on the bottle.
The patient followed up with the provider to inform them of the incorrect prescription. The provider then sent a prescription for lisinopril 10 mg, take one tablet by mouth daily. This prescription was filled by the pharmacy but not picked up due to this also being an error. The patient contacted the prescriber again. The prescriber confirmed she had made a human error when entering the dose as 10 mg instead of 30 mg. She confirmed she would correct the medication list on file. Then, she entered the medication as lisinopril 10 mg, take 3 tablets by mouth daily for 30 days instead of lisinopril 30 mg, take one tablet by mouth daily for 90 days.
When a different pharmacist was verifying the latest prescription, they stopped the line, called the patient, and confirmed that he was not taking 90 mg daily. The pharmacist also indicated that he would be following up to review what happened with the previous incorrect prescriptions. No further information was shared with the patient from the pharmacy.
Upon follow up, the prescriber shared that she was thankful for the patient’s attention to detail and for being aware of the risks that may arise with a prescription error. She said that she has to keep a “close eye” on other patients who she knows are unable to do this for themselves. Unfortunately, this was viewed as inevitable rather than an opportunity to learn and improve systems.
Pharmacists should work with vendors and internal system analysts/developers to ensure the EHR or pharmacy dispensing system provides clinical decision support with dose range checking and warnings. Systems should be able to identify doses that exceed established maximum doses and present an interactive alert to the prescriber and/or pharmacist that requires acknowledgment. Pharmacies should test their dispensing systems to ensure that they will intercept doses that exceed established maximum doses.
It is imperative that organizations plan ahead and prepare staff to respond to errors. This includes preparing staff to stop the line at the point-of-sale and investigate the patient’s concern if they say their prescription is incorrect. Policies on disclosure and apology to patients and caregivers are also a must. Review and discuss these policies and procedures with the pharmacy team so that the process is clearly understood. Regularly review the procedures for appropriateness. The policies and procedures should contain specific guidance on what to say and do, who should be contacted, particularly when all the facts of the case may not be immediately known, and who will follow up. Define when others (e.g., prescribers) should be notified of an error. Practice and role-play possible scenarios with all staff. ■