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Error Number 143. Trying to fill an order that doesn't include tablet strength

When a drug is available in only one strength, why bother to insist that the doctor specify strength in his medication order? Because drugs are sometimes marketed in strengths that you may be unaware of.

In one case, a doctor wrote this order:

A nurse noted the order in her records. Then, because she thought the drug came in only one strength, the nurse added 12.5-mg tablets to the doctor's order and sent it to the pharmacy. The pharmacist saw the addition and assumed the nurse had checked tablet strength with the doctor.

Two days later, the doctor made rounds and saw that his patient wasn't responding well to the Antivert. When the nurse told him what dosage she'd been administering, the doctor told her he'd meant the patient to receive Antivert in a 25-mg tablet strength.

Clearly, the doctor could have avoided this error if he'd included tablet strength in his medication order. But when he didn't, the nurse should have checked with the doctor before she sent his order to the pharmacy.