Error Number 156. Allowing unqualified personnel to administer drugs

When the stock of injectable vitamin B₁₂ was exhausted on a hospital unit, someone on the nursing staff called the pharmacist. Until the new supply arrived, she asked, would it be all right to substitute two doses of vitamin B₁₂ for the prescribed B₁₂

This actually happened. And although laughable, it points to a fact of life ... that we sometimes have inexperienced and possibly unqualified persons involved in administering medications.

The best way to guard against serious errors in these situations is to make sure you have a drug distribution that encourages checking and double-checking. You should also encourage ques¬tioning. Don't laugh at people when they ask what seems like a silly question. You may discourage them from asking other important questions in the future.