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Patient safety is all about taking that extra step.



From the July 11, 2001 issue

PROBLEM: We're often reminded of medication errors that have been prevented by healthcare practitioners who are diligent enough to fully investigate situations that "just don't seem right," even after there's been an initial confirmation by an authoritative source. Taking this "extra step" can often prevent patient harm. Such a case was reported last week. A patient with several medical conditions, including glaucoma and diabetes, was admitted to a hospital with medication orders that included "glucose control solution one-drop to left eye twice a day." Since this substance is actually used to verify proper functioning of glucose monitoring devices, the pharmacist questioned the nurse and prescriber, both of whom stated "that's what the patient uses at home." The pharmacist then took the time to question the patient directly. Indeed, the patient said that he'd been instilling glucose control solution into his left eye at home and thought this was the correct way to use the medication, based upon instructions from his local physician. The pharmacist, still not satisfied, telephoned the original prescriber who indicated that, actually, timolol ophthalmic solution was to be used for the patient's glaucoma. The pharmacist later discovered that the diabetic patient, with very poor eyesight, had interchanged the glucose control solution with the timolol (both products are available in small dropper containers with yellow caps and black lettering - see photograph on our web site with this week's issue).

Patient mistook glucose control solution above for timolol Same container with front label panels visible

SAFE PRACTICE RECOMMENDATION: Consider publicizing some of the phrases used to justify a questionable order before an error becomes apparent. Add additional reasons as appropriate. Pledge that these statements - shortcuts really - won't be used or at least won't be allowed to dissuade anyone from performing additional follow up:

  • "That is what the doctor ordered"
  • "The attending told me to order it that way"
  • "The patient (or Mom) says that's how they take it at home"
  • "It was published in recent literature (journal reference cited)"
  • "This is a special case"
  • "The patient's been titrated up to that dose"
  • "The patient is on a protocol"
  • "The dose is from the patient's old chart"
  • "It's on the list of meds the patient gave me"
  • "We always give it that way"

When medication orders do not seem quite right, pharmacists, nurses, and physicians must take that "extra step" to verify an order before a medication is prescribed, dispensed, or administered to a patient. In the example cited above, the pharmacist did not just take the word of the physician, nurse, or patient, all of whom said that the prescription was accurate. During orientation of new staff, and continuing education of current staff, we must instill the thought that the "reasons" cited above are unacceptable responses if an order is questioned. Practitioners must have the support of colleagues and management to pursue questionable medication orders until there is absolute satisfaction that the order is appropriate. A link to a process for resolving drug therapy conflicts appears on our web site with this week's issue.

From the ISMP Medication Safety Alert! - May 20, 1998
Suggestions for resolving conflicts in drug therapy

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