drug, and the patient Hypotension experienced hypotension Drug prescribing error When patient became No Off label use pregnant, neurologist switched her to an Drug use for extended release product unapproved dosing twice daily (off label) regimen instead of recommended once daily administration Patient accidentally Yes Duplicate drug received duplicate therapy prescription because the prescriber didn’t realise the 2 drugs Duplicate therapy had the same active error ingredient Product selection errors/issues Scenario Medication LLT Comment error? The patient confirmed that Yes Product selection This is not a product name due to the cataract, the error confusion. patient did not see well Cataract would be captured and ended up buying the as medical history. infant formulation Pharmacist selected the Yes Intercepted wrong It is important to capture the wrong drug because of drug selected of the error name confusion, but the error was caught and Drug name confusion corrected before the drug was dispensed The hospital selected the Yes product selected wrong bag and the patient received a transfusion of Transfusion with the wrong blood type prior incompatible blood to and during surgery ordered the wrong Yes Wrong drug selected drug from the wholesaler because the drugs were Drug name look-alike
drug, and the patient experienced hypotension Hypotension Drug prescribing error When patient became pregnant, neurologist switched her to an extended release product twice daily (off label) instead of recommended once daily administration No Off label use Drug use for unapproved dosing regimen Patient accidentally received duplicate therapy because the prescriber didn’t realise the 2 drugs had the same active ingredient Yes Duplicate drug prescription Duplicate therapy error Product selection errors/issues Scenario Medication error? LLT Comment The patient confirmed that due to the cataract, the patient did not see well and ended up buying the infant formulation Yes Product selection error This is not a product name confusion. Cataract would be captured as medical history. Pharmacist selected the wrong drug because of name confusion, but the error was caught and corrected before the drug was dispensed Yes Intercepted wrong drug selected Drug name confusion It is important to capture the of the error The hospital selected the wrong bag and the patient received a transfusion of the wrong blood type prior to and during surgery Yes product selected Transfusion with incompatible blood ordered the wrong drug from the wholesaler because the drugs were Yes Wrong drug selected Drug name look-alike
000199_companionptc_r1_01_jun2018.docx