Error Number 150. Failing to assess medication orders routinely

A patient admitted for surgery brought with him some medications he'd been taking at home. Among them was a bottle of digoxin, containing tablets of 0.25 mg but labeled 2.5 mg. When the admitting doctor read the label, he wrote a pharmacy order for digoxin, 2.5 mg daily, without questioning the unusually high dose. Further, since the patient was to have nothing by mouth the day of surgery, the doctor ordered that day's dose to be given by injection.

Since the hospital used a partial floor-stock system, the nurse received a copy of the order and due to her inexperience did not suspect the order was in error. She administered the first dose before the hospital pharmacist could review it. When the pharmacist finally received the digoxin order along with the patient's medications from home, he immediately realized the dose was much too high. He checked the patient's bottle, saw that it was mislabeled, and realized what had happened.

The pharmacist called the nurse's station to report the error but was told the patient had already received his daily dose of digoxin by injection and had gone to surgery.

How many individual mistakes contributed to this medication error? First, the neighborhood pharmacist mislabeled the patient's digoxin bottle. Second, the admitting doctor took a shortcut and copied the order from the mislabeled bottle, rather than from the patient's prescription records. He compounded his mistake by failing to question the unusually high dose of a common drug and he changed the administration route without reducing the dose. These mistakes caused a toxic dose to be administered.

Third, the nurse giving the drug didn't assess the order-if she had, she'd have known the dose was too high. And since the hospital used some drugs from floor-stock, the hospital pharmacist didn't review the doctor's order until after the first dose was given.

This medication error occurred because the hospital's system of checks and balances broke down. To maintain that system methodically assess every medication order:

• when you first receive the order, to confirm that it makes sense
• when you obtain the medication
• when you prepare it for administration
• when you give it to the patient.

Additionally, make certain that you know the purpose of the drug, its dose, its contraindications, and its nursing implications.