| Contents | Previous | Next |
A patient complaining of chest pain, weakness, and dizziness was admitted to a hospital emergency department. The admitting nurse contacted the patient's doctor and took his telephone orders, including an order for what she heard as "Inderal Forte," one tablet daily.
The nurse called the pharmacy to request the antiarrhythmic Inderal (propranolol), and when it was delivered, she immediately took it to the patient. Before allowing her to administer it, though, the patient asked the nurse to tell him the drug's name and explain its purpose.
When the patient's doctor arrived, the patient asked why he'd been given Inderal, which wasn't one of his usual medications. Puzzled, the doctor asked the nurse why she hadn't given what he'd ordered: Enduranyl Forte, which combines methyclothiazide, a thiazide diuretic, and deserpidine, an antihypertenSIve.
The nurse then realized she had misunderstood the doctor when she took his phone order, hearing "Inderal" for "Enduranyl." Giving Inderal had made sense to her since it is used for certain forms of chest pain. She assumed that "Forte" indicated an enhanced dosage form. Fortunately, the one dose of Inderal didn't harm the patient.
This error occurred because the hospital's system of checks and balances wasn't followed. The nurse didn't repeat the drug's name when she took the doctor's phone order. The pharmacist also didn't repeat the drug's name when the nurse phoned in her request. He thought that she'd asked for Inderalforty, that is, a 40-mg tablet. Although the pharmacist thought 40 mg of Inderal daily was an unusual order, he didn't ask the nurse to check back with the doctor.
To prevent such an error, follow these guidelines: Always repeat an order you take over the phone. If the drug being ordered doesn't sound familiar, ask that the name be spelled out. Be sure the doctor signs the verbal order within 24 hours, or according to hospital policy.
Know the drugs you administer. Don't assume an unfamiliarsounding name is a new drug or dosage form. If necessary, ask the patient or his family what drugs he usually takes. If the patient has the drugs with him, ask to see them.
Finally, tell the patient what you're giving him and listen to his concerns. In this case, the patient discovered the error because he questioned a drug unfamiliar to him.