1. Medication Safety

2. Angelina Jolie was ordered Lasix® 1 mg/kg via IV push
Angelina Jolie was ordered Lasix® 1 mg/kg via IV push. Brad Pitt, RN, obtained the vial of IV medication, but gave it to Angelina orally.

3. Administration Error

4. Matt Damon was prescribed Ciprodex® otic suspension- 4 gtts AS BID
Matt Damon was prescribed Ciprodex® otic suspension- 4 gtts AS BID. Ben Affleck, RN, administers the medication in his left eye, twice a day.

5. Administration Error

6. Doctor Phil calls CVS to phone in a prescription for Oprah Winfrey, who will be discharged today. He wants the following prescription: Plavix 75 mg #50, 1 po daily The pharmacist transcribes the prescription as follows:
Patient Name: Oprah Winfrey
Address: 123 Madeup Lane, Deerfield IL 60015
Rx Plavix 75 mg tablets Disp#15
Ṫ cap po every day
Signature: Dr Phil

7. Dispensing Error

8. Doctor Drew calls CVS to phone in a prescription for patient Susan Pinsky. He wants the following prescription dispensed:
Amoxicillin 500 mg, 1 cap po TID x 10 days.
The pharmacist dispenses 21 capsules of Amoxicillin to the patient.

9. Dispensing Error

10. Doctor Who writes the following prescription for his patient who will be discharged today.
Patient Name: David Tennant
Address: 123 Madeup Lane, Deerfield IL 60015
Rx Warfarin #XV
1 tab po every other day
Signature: Doctor Who, MD

11. Prescribing Error

12. What type of workplace issues may contribute to medication errors?

13. Noise
Stress
Multi-Tasking
Similar medication labels
Medication labels that are difficult to read

14. Name 2 items on the Joint Commission's “Do Not Use” list, and explain why they are on that list.

15. Do Not Use Item
Potential Problem
Use Instead
U, u (unit)
Mistaken for zero, the number 4, or CC
Write “unit”
IU (international unit)
Mistaken for IV (intravenous), or the number “10” ten.
Write “international unit”
Q.D., QD, q.d., qd (daily)
Mistaken for each other
Write “daily”
Q.O.D., QOD, q.o.d., qod (every other day)
Period after the “Q” mistaken for “I” and the “O” mistaken for “I”
Write “Every other day”
Trailing Zero (X.0 mg)
Decimal point is missed
Write X
Lack of leading zero (.X)
Write 0.X mg MS
Can mean morphine sulfate or magnesium sulfate
Write “morphine sulfate”

16. To prevent confusion between the following drugs, how should they be written on a prescription? Glyburide & Glipizide

17. glyBURIDE
glipiZIDE

18. To prevent confusion between the following drugs, how should they be written? Prednisolone & Prednisone

19. prednisoLONE
predniSONE

20. The ISMP has established a list of medications that should never be crushed before administration. Everybody, give one reason why a medication may be on that list.

21. Slow-release dosage form
Extended release dosage form
Enteric coated dosage form
May irritate the mucous membrane
Rate of absorption may be increased
Coating of tablet may release the drug over a period of time
Taste
Skin irritant
Liquid Filled
Sublingual dosage form
Film-coated dosage form
Effervescent tablet
Teratogenic effect
Local anesthesia of the oral mucosa

22. A pharmacy technician may ask patients if they have any questions about their medications, but it is the pharmacist’s responsibility to counsel a patient. Let’s Role Play! Can you answer the following questions, or do you have to refer them to the pharmacist?

23. What medication did my doctor prescribe?

24. Do I need to take this medication with food?

25. My birthday is tonight and I would like to have a glass of wine with my dinner. Is it safe with this medication?

26. Am I supposed to swallow this medication or inject it?

27. Can you please tell me how to take this medication?

28. How do I know when I can stop taking this medication?

29. My husband and I are trying to get pregnant
My husband and I are trying to get pregnant. Is this medication safe to take if we succeed?

30. Items that can be discussed with a Pharmacy Technician:
Name of medication
Dosage form
Dosage
Route of administration
Items that must be discussed with a Pharmacist:
Duration of therapy
Action to be taken if a dose is missed
Common or severe side effects
Interactions and contraindications of the medication (to include food)
Self-monitoring of medication
Proper storage of medication
Special directions for use
Questions:
My doctor prescribed me something, but didn’t tell me what it is. What is the name of the medication?
I have high blood pressure. Is this medication is going to make it better?
My sister says I should never store this medication in the bathroom. Is that true?
I’m not sure whether my doctor prescribed me the tablets or the syrup. Do you know?
My Doctor was supposed to give me 2 mg tablets. Can you tell me what strength was written on the prescription?
Will this medication interact with the sudafed I’m taking for my stuffy nose?

31. Many medications are inappropriate to use in the elderly population due to adverse side effects. Name a few adverse side effects that are especially worrisome in this population, and explain why they’re worrisome.

32. Anti-cholinergic effects
Drowsiness
Confusion
Constipation
Cardiac Problems
Carcinogenic Effects
Hypoglycemia
GI Bleeding
Anti-cholinergic effects
Questions:
My doctor prescribed me something, but didn’t tell me what it is. What is the name of the medication?
I have high blood pressure. Is this medication is going to make it better?
My sister says I should never store this medication in the bathroom. Is that true?
I’m not sure whether my doctor prescribed me the tablets or the syrup. Do you know?
My Doctor was supposed to give me 2 mg tablets. Can you tell me what strength was written on the prescription?
Will this medication interact with the sudafed I’m taking for my stuffy nose?

33. What is the FDA MedWatch?

34. A voluntary program that allows the voluntary reporting of adverse health events and medical problems.

35. What is FAERS?

36. FDA Adverse Event Reporting System

37. A database that contains information on adverse event and medication error reports submitted to the FDA.

38. What is the benefit of electronic prescribing?

39. Eliminates illegible prescriptions
Uses clinical decision support to reduce preventable errors
Improves communication between the clinician and patient
Enhances communication throughout the prescribing chain
Increases access to patient and reference information
Improves work efficacy

40. What are the advantages of pharmacy automation?

41. Reduction in medication errors
Increased speed in medication processing
Manage and track inventory