3 Examples of Medication Errors I’ve Seen in My Practice

Medication errors happen all the time.  I have routinely reviewed medication errors for numerous institutions. I wanted to share three examples of medication errors that I’ve seen in my career.  I would also encourage you to share any that you have seen in the comments section just to help others be aware of possible scenarios to look out for.

The first example was an issue due to handwriting.  The provider had written for Celexa 20 mg, but because of poor/blurry handwriting, this got interpreted into Celebrex 200 mg.  You can definitely see how these could be misinterpreted.  A good discussion with the patient would hopefully help prevent this one if the patient recognizes what indication they wanted to be treated for.

The second: I have seen numerous errors involving insulin in long term care.  One of the scariest I’ve seen is higher dose insulin and patients on both long acting (i.e. glargine) and short acting.  In one scenario, a patient was given 35 units of rapid acting insulin when the dose was intended to be for the long acting.  The caregiver did recognize the mistake after the dose was given.  Close monitoring and plenty of carbs were given and the patient was ok.

Last: Acetaminophen and acetazolamide 500 mg four times daily.  This error fortunately did not reach the patient, but the potential was there and this could have certainly had some dire consequences.  As a healthcare professional, this should emphasize the importance of recognizing common doses.  I can’t recall a time that I have ever seen acetazolamide 500 mg four times daily.

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  1. Shawn Reidy

    There is also a danger of using obscure abbreviations by physicians. I once received an order in the hospital that I was working in- a teaching hospital with plenty of residents. The order read as “DPH 200 Qhs”
    One could interpret that as diphenhydramine (Benadryl) 200mg, which is excessive but not impossible. It occured to me that it might mean “diphenyl-hydrantion – the chemical designation for phenytoin!! and 200mg at hs would be a reasonable dose for that drug. It turned out, after contacting the resident, that that WAS what he meant?!! I couldn’t help but lecture him NOT to use that abbreviation again, since another pharmacist could have filled it as diphenhyramine. The resident thanked me and I never saw an order like again.

  2. Ahmed

    Many medication errors have been encountered. One example involved an old lady prescribed salbutamol inhaled solution. Instead of administering through a nebuliser machine, she drank the solution. Not providing enough instructions to her by the oharmacust caused this error.

  3. Ahmed

    Definitely, there is a need to emphasise the role of clinical pharmacists in preventing medication errors.

  4. Alan Vogenberg BS-Pharm, FASCP

    An east method to help prevent some of the errors you list is for the prescriber to indicate the diagnosis on the Rx. ie: Benadryl 200mg hs for sleep or Dilantin 200mg for seizures, Coprtisporin Otic for ear infection, etc.

  5. Kavita

    Writing generic ingredients can cause problems – fluticasone comes as nasal spray and inhaler sp if sig is spray .always mention dosage form with brand name . If u r changing dose indicate that on rx , if u r aware about other narcotic or controll sub they got recently mention that on rx that saves lots of time .


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Written By Eric Christianson

October 16, 2016

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