Third, when execution of any order appears to call for an unusual medication amount or frequency, revisit the order or prescription and secure a second opinion. The hospital’s stores were depleted, underscoring the fact that the amount being dispensed to a single patient was excessive. Acetylcysteine is prepared as 200 mg/mL in 30-mL glass vials. Correct treatment for this patient would have required about 2.5 vials, but she was administered 30 vials. Quite practically, this should have raised red flags. If you bring 30 vials of one substance into a room, find yourself reconstituting 11 vials of a drug, or preparing a dozen syringes for one patient, recheck your dosing and get a second opinion before administering.
Fourth, whenever possible, verify that the dose to be administered is “in the ballpark” and generally reasonable to avoid excessive overdose—such as the dreaded 10-fold dosing error. Here, we know the patient weighed 48 kg (106 lb), and that her 21-hour dosing was 14,600 mg; a 70-kg patient (154 lb) would get a 21,000-mg total over 21 hours—in the same general ballpark. It should be clear that 180,000 mg is approximately 10 times out of the ballpark. Of course, use appropriate substance-specific judgment: When medications have a narrow therapeutic range or are titrated to effect, a general ballpark concept is inappropriate. Though useful, a fast check to estimate that your calculations aren’t wildly off may not suffice to detect smaller-scale yet important errors.
Fifth, always use caution when continuing orders from another clinician. You are prescribing under your authority, and it is important to independently check the order and not blindly ratify the actions of another. You owe the patient an individual analysis, and jurors will hold you individually responsible for medication errors. When you are called upon to continue an order, make your own assessment and, though sometimes difficult, be prepared to question an order if you are concerned. Consider seeking a colleague’s opinion on the propriety of the initial order as well.
Lastly, to minimize the risk for medication errors, follow good general prescriptive and ordering practices. Write legibly, spell out directions or terms commonly misinterpreted (and a source of litigation): Use “daily” instead of “qd,” “international units” or “units” instead of “IU.” Spell out “magnesium sulfate” or “morphine sulfate,” not “MgSO4” or “MSO4.” Include indications (to avoid prescribing the wrong drug and to remind the patient of the medication’s function) and with decimal points, “always lead, never trail” (eg, write “10 mg,” not “10.0 mg”; write “0.5 mg,” not “.5 mg”). Dispense the correct substance-specific amount, with refills only when appropriate, and confirm the patient’s identity.
Regarding allergies, I have always used a burst of three questions: Do you have any allergies? Are there any medications you cannot take? Have you ever been told that you should not take any medication? I have been surprised when a patient answers affirmatively to one question but negatively to the other two.
Recommend that patients use one pharmacy to allow the pharmacist and pharmacy professionals to monitor for duplications, interactions, and allergies to prescriptions issued by different prescribers. Technology continually brings us more medications, and patients commonly have prescription lists in the double digits; respond with technology of your own. Use multidrug interaction checkers, such as Medscape.com or Epocrates.com, which offer free browser-based and app options. Employ these assets in conjunction with and not in lieu of your own training, skill, and experience to minimize adverse drug interactions. —DML