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A doctor wrote an order for Sinemet 10/100 (carbidopa-Ievodopa) for Mr. Flannery, a patient with Parkinson's disease. That evening, a nurse mistakenly transcribed the order onto the medication administration record (MAR) for Mr. Miller, Mr. Flannery's roommate.
In the meantime, a copy of the doctor's order for Mr. Flannery was sent to the hospital pharmacy. The pharmacist dispensed the Sinemet into Mr. Flannery's bin in the drug cart.
When the medication nurse was ready to administer the drugs, she checked Mr. Miller's MAR, saw the order for Sinemet, and went to his bin in the drug cart to get it. Puzzled that the Sinemet wasn't there, she checked the other bins and found it in Mr. Flannery's. She checked his MAR-it had no order for Sinemet.
Thinking the pharmacist had put the Sinemet in the wrong bin, the nurse took the drug from Mr. Flannery's bin and administered it to Mr. Miller. She continued to administer Sinemet to Mr. Miller (taking it from Mr. Flannery's bin) for 2 days.
The error was discovered when Mr. Miller's doctor checked his patient's MAR and saw the order for Sinemet-an order he'd never written. Although Mr. Miller suffered no ill effects from the Sinemet, Mr. Flannery had not received drug therapy for his Parkinson's disease for 2 days.
A mistranscription, an error in judgment, and a lack of drug knowledge contributed to this medication error.
First, the transcribing nurse wrote the order on the wrong MAR-an error that went undiscovered for 2 days. This error could have been prevented if the hospital had a policy of checking the doctor's original order against the patient's MAR within the first 24 hours after an order is written.
Second, the medication nurse switched the drug from one patient's bin to another-defeating a safeguard of the pharmacy's unit-dose system. The nurse should have called the pharmacist when she saw that the drugs in the cart didn't correspond with the patients' MARs.
And third, she could have compared the drug she was administering with the patient's diagnosis. Then she would have questioned why an antiparkinsonism drug was ordered for a patient who didn't have Parkinson's disease.
So if you're responsible for transcribing drug orders, check the name on the MAR first, and be sure you're writing on the right record.