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Volume XXV, Number 1                                                         Fall/Winter   2000/2001

COMPLAINT CORNER

Allison Benz, R.Ph.
Assistant Director of Enforcement

Between September 1, 1999, and August 31, 2000, Fiscal Year 2000, the Board entered 43 disciplinary orders alleging that at least one error had occurred. After reviewing the orders entered in Fiscal Year 2000, the following statistics are applicable:

• 43 orders described 71 alleged dispensing errors;

• 37% of the orders involved more than one alleged error;

• 37% of the errors allegedly caused negative patient outcomes; and

• 25% of the errors allegedly involved pediatric prescriptions.

The disciplinary orders included the following types of errors:

TYPE OF ERROR PRESCRIPTION ISSUED FOR INCORRECTLY DISPENSED AS
WRONG DRUG Prempro tablets

Propranolol 20 mg tablets

Tegretal 200 mg tablets

Ciloxin ophthalmic drops

Duricef 500 mg capsules

Ritalin 5 mg tablets

Accupril 10 mg tablets

Klonopin 1 mg tablets

Ceftin 125 mg/5ml suspension
Premphase tablets

Prednisone 20 mg tablets

Trental 400 mg tablets

Xalatan ophthalmic drops

Diuril 500 mg tablets

Methadone 5 mg tablets

Accutane 10 mg capsules

Clonidine 0.1 mg tablets

Cefzil 125 mg/5 ml suspension
WRONG STRENGTH Wellbutrin 75 mg tablets

Lodine XL 600 mg capsules

Coumadin 1 mg tablets

Augmentin 400 mg tablets

Vasotec 5 mg tablets

Compazine 2.5 mg suppository

Wellbutrin 150 mg tablets

Lodine XL 400 mg capsules

Coumadin 5 mg tablets

Augmentin 250 mg tablets

Vasotec 20 mg tablets

Compazine 25 mg suppository


WRONG DIRECTIONS

Albuterol Syrup


Trimox 250mg/5ml Suspension

Depakote 125 mg Tablets

Gantrisin 500mg/5ml Suspension

Amoxil 500 mg Capsules




1 ½ ml
three times daily


2.5 ml three
times daily


2 tablets twice daily

1 ½ teaspoonsful daily


6 capsules
1 hour before appointment & 3 capsules 6 hours later appointment
 



1 ½ teaspoonsful
three times daily

2.5 teaspoonsful three times daily

2 tablets three times daily

1 ½ teaspoonsful twice daily at bedtime

2 capsules 1 hour before appoinment & 3 capsules 6 hours later

Approximately 27% of the 71 errors which resulted in disciplinary orders may have been detected (and thus prevented) if a pharmacist had verbally counseled a patient or patient’s agent. For example, errors involving the "wrong directions" can generally be detected if the pharmacist will be on the alert when reading the label directions to the patient. In addition, approximately 58% of the 71 errors may have been detected if the dispensing or consulting pharmacist had looked inside the prescription container and compared the contents to the drug name on the prescription label, before giving the prescription container to the patient or patient’s agent. Accordingly, the Board encourages pharmacists to read the drug name on the label and look inside the prescription container, before giving the medication to the patient/patient’s agent. Pharmacists are also encouraged to review errors that may have occurred in the pharmacy, evaluate their practice setting, and then make any changes necessary to prevent errors from occurring in the future.

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