Lesson 4 - Medication Errors Assignments Assignment 1 - Case Study Review the Case Study on page 314 of the Pharmacy Technician Practice and Procedures textbook. Then answer the following questions. 1. Who could have prevented the overdose from occurring? 2. What should the pharmacy team have done when filling the prescription? Assignment 2 - Critical Thinking Questions 1. Assume you are a patient and the pharmacist informs you that you received the incorrect strength of the medication. How would you react? 2. If you were a pharmacist, would you admit that you made a prescription error to a patient? Why? 3. Should a healthcare organization punish individuals for reporting prescription errors that they made or commend them for their honesty? Why? Assignment 3 - HIPAA Scenario Read the following scenario and answers the questions that follow. Elena Rodriguez, CPhT, a retail pharmacy technician, is filling a prescription for 30 0.125 mg generic digoxin tablets for patient Carol Mason. Upon opening the stock bottle to count out 30 tablets, Elaine notices that the stock bottle contains both white and yellow tablets of the same size. The color of the generic digoxin 0.125 mg tablets from the manufacturer is yellow. Elena believes that what most likely happened is that either a pharmacy technician or a pharmacist had previously removed both the 0.125 mg generic digoxin and 0.25 mg generic digoxin stock bottles from the shelf at the same time, opened the stock bottle of the 0.25 mg generic digoxin (white) tablets, and after counting out the number of tablets needed to fill the prescription, accidentally put the extra 0.25 mg generic digoxin (white) tablets into the wrong bottle of 0.125 mg generic digoxin (yellow) tablets. Drug Name Digoxin Strength(s) 0.125 mg Drug Name, Imprint(s), Manufacturer/Distributor Duramed Drug Name Digoxin Strength(s) 0.125 mg Imprint(s) Lanoxin Y3B Manufacturer/Distributor Vangard Labs Inc. Drug Name Digoxin Strength(s) 0.25 mg Drug Name, Imprint(s), Manufacturer/Distributor Duramed
1. What should the technician do? 2. Should Elena separate out the two colors of tablets and place the white tablets into the bottle of 0.25 mg digoxin? 3. What impact, if any, on previous patients does the scenario present? 4. What questions should the technician and pharmacist have? 5. How does the scenario relate to HIPAA? Assignment 4 - Apply Your Knowledge Identify the error in each prescription. RX 1: Hydrochlorothiazide 50 mg #30 1 tab po at q hs RX 2: Ambien 10 mg #30 (Note: controlled substance) 1 tab po q hs prn insomnia Refill 6 RX 3: Nitroglycerin 1/150 gr #25 1 tab po at qd prn angina RX 4: Lipitor 10 mg #30 UD RX 5: Demerol 200 mg #20 1 tab po q 4 hours prn pain RX 6: Anusol HC Supp #12 1 supp po q 4-6 hrs prn hemorrhoids Refill 1 RX 7: Amoxicillin 250 mg/5 ml 150 ml 1 tsp IV q 8 hrs Refill prn RX 8: Prednisone 5 mg #100 1 tab po qd for 5 days, then 1 tab po bid, then 1 tab po tid for 5 days, then 1 tab po qid prn respiratory problems
RX 9: Ibuprofen 800 mg #30 1 tab po q 4 hrs on an empty stomach Refill 1 RX 10: Cortisporin Otic Solution 1 gtt ou prn ear infection Refill 8 ml Rx. 11 Mary E. Shed March 10, 2012 1000 Wilson Blvd. Arlington, VA 22209 Inderal 5 mg #30 1 tab po every day Refill 3 Rx. 12 FP5555555 Hector Belt March 8, 2012 1000 Armstrong Ave. Robitussin AC 240 g 1 teaspoonful po q 6-8 hrs prn cough
Rx. 13 Matthew Shult March 9, 2012 200 Thomas Jefferson Way Cortisporin Otic Soln 8 ml Instill one drop in right eye for conjunctivitis Rx. 14 Patrick Amano March 1, 2012 100 Brown Belt TKD Way Great Falls, VA 11111 Amoxicillin 250 mg/5 ml Suspension 150 ml Inject 5 ml every 8 hours Rx. 15 Matt Jones March 6, 2012 2222 Subunit Rd. Reston, VA 20190 Tessalon Perles #30 Chew one perle q 8 hours Refill 1
Assignment 5 - Practice Your Knowledge Use the website: www.ismp.org to locate the ISMP list of confused names and identify all of the drugs that may be mistaken for the one given in the following table. This assignment will help you to become familiar with medications that have been the source of medication errors due to the similarity of their names. Medication Prescribed Amaryl Confused Drug Names Celebrex Celexa Clozaril Coumadin Cozaar Depakote Diovan Diprivan Estratest Humulin Inderal Kaletra Lanoxin Lasix
Lexapro Lodine Maxzide Metformin Myleran Neumega Pamelor Paxil Percocet Prilosec Protonix Reminyl Ritalin Roxanol Sarafem Tegretol Tequin TobraDex
Tylenol Wellbutrin Zebeta Zyprexa Zyrtec Zyvox