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Premarin 0.625 mg was ordered for a patient. No 0.625 mg tablets were available in the pharmacy. The pharmacy technician decided that he would give an equal dose by using a number of tablets of a "lesser" strength. Apparently he thought the dose was 6.25 mg. He placed five 1.25 mg Premarin tablets together in a unit-dose package and placed these in the patient's bin of a unit-dose cart. The medication nurse, upon receiving the cart, returned with the dose to question the use of the five tablets, and was told by the technician that the dose was correct. The pharmacist was not consulted about the dose by the technician or the nurse, although he was present in the pharmacy at the time. The patient, who had gynecologic problems in the past, received the dose and exhibited vaginal bleeding three days later. The cause
of the bleeding was later discovered and explained to the patient.
Two important points need to be made in considering this medication error. First, pharmacists must make every effort not to substitute smaller dose tablets or capsules to equal a larger dose. Not only do patients have more tablets to swallow, there's a greater chance an error will occur or that only part of the dose will be given.
Second, if you do find yourself needing to give more than one or two capsules, vials, tablets, ampules, etc., chances are there's something wrong. So check with another nurse or your pharmacist.