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Checking procedures

  • Be particularly careful when choosing the dose for a drug you are not familiar with.
  • If a pharmacist or nurse questions a drug order or prescription, check it carefully – many problems are prevented by helpful interaction between colleagues.
  • Always read the label on the bottle or vial before administering a drug or other substance, such as water for injection.
  • Establish the identity of the patient and double-check the prescription before administering medication.

Communication

It is often necessary to order medications over the telephone, but this is a notoriously risky practice because your instructions may easily be misheard or misunderstood (see the case report below). When ordering drugs or other treatment over the telephone, you should always ask the recipient to repeat your instructions back to you so you can be sure they were received correctly.

When ordering drugs or other treatment over the telephone, you should always ask the recipient to repeat your instructions back to you so you can be sure they were received correctly

Case report: Misheard verbal prescription leads to patient’s death

A patient, in the course of treatment in an acute hospital, was given parenteral morphine. The patient was sensitive to the drug and developed respiratory depression. The patient’s doctor called in an order for an ampoule of naloxone to be administered. A dose was prepared from ward stock and given but there was no response. A repeat order for a second ampoule of naloxone was also given and again the patient showed no improvement.

The nurse then questioned the doctor: “How much of this Lanoxin do you want me to give?” Instead of NaLoxone, the nurse heard LaNoxin. The patient subsequently died. Contributing to the error, the nurse had not repeated back the verbal order to the doctor, and the doctor had prescribed an ampoule of the drug rather than a metric weight dose. The nurse had accepted the incomplete order and administered an ampoule of LANOXIN® (digoxin) both times.

(Irish Medication Safety Network, Briefing Document on Sound Alike Look Alike Drugs (SALAD) 2010.)

General advice regarding communication

  • If you are prescribing medication to be administered by other members of the healthcare team, issue clear and unambiguous instructions – answer fully any queries they may have.
  • Make sure that your outpatients understand how to take the medication you prescribe, and that you warn them of any possible serious side-effects or effects that would make driving or operating machinery dangerous.
  • Document the administration of drugs and infusions (name, time, dose) in the appropriate place in the medical records.