Unclear prescriptions can trigger a cascade of serious events. See if these 5 caught by one pharmacy team look familiar, and beware.
Any pharmacist that has been practicing for a while has seen their fair share of prescription gaffes. Of course medication errors are a serious issue and unclear prescriptions can contribute, but today I am going to keep it light with a review of 5 of the most “notable” prescriptions I have seen recently. Most of them, of course, were followed up with a phone call to the doctor’s office! Click through the quick slideshow to get more details and see if any of these “head scratchers” look familiar to you.
Probably not the best way to write a half-tab. Even for larger tablets, an important point that should not be overlooked is the inaccuracy that is inherent in pill-cutting. One study, for example, found that out of 1752 split tablets, 41.3% deviated by >10% of their ideal weight and 12.4% deviated by >20%. The authors also found that about three-quarters of study patients were willing to pay more for a commercially-prepared, lower strength tablet rather than split tablets in half.
Apply the Lotrisone® where? Note that “OU” is on the Institute for Safe Medication Practices’ (ISMP) dangerous abbreviations list because it can be mistaken for “AU” and, based on my own experience, can also be mistaken for “QD,” which is also on the ISMP list. Misinterpretation of route in the clinic has resulted, for example, in oral liquids being administered via injection including the Rotavirus vaccine.
How many refills do you want? An interesting note on this prescription is the fact that the quantity is circled halfway between the “75-100” and “101-150” but “#10” is written on the prescription. That naturally lead us to question if the quantity intended was actually 100 or if 10 was correct, but the circled quantity was supposed to be “1-24.”
And, how many refills do you want? As I wrote in a previous article, precise handwriting is a good example of how to avoid a phone call from your friendly pharmacist.
Diagnosis: Severe obesity due to excess calories. While it is hoped that a patient would ignore or perhaps laugh at such an item (although it could be an accurate, albeit crude assessment), there have been occasional lawsuits and disciplinary actions for personal insults, so caution is advised. While this case is of course in a completely different league, here is a somewhat recent example of a lawsuit stemming from comments that were offensive to the patient. For tips on effective techniques for counseling patients on weight loss, check out this great resource from the National Institutes of Health.