ILLEGIBLE ORDER
A pharmacist who'd received a poorly handwritten prescription from a psychiatrist conferred with five colleagues, and all believed the prescription was for the antipsychotic Loxitane (loxapine), 10 mg. After 6 days, the physician questioned why his patient wasn't receiving the selective serotonin reuptake inhibitor Lexapro (escitalopram), which he'd ordered several days earlier.
Similar names and dosage strengths (10 mg) of the two medications contributed to the confusion in this case, but interpreting illegible orders "by committee" is dangerous. The hospital where this error occurred now requires nurses to compare any newly prescribed psychotropic medication with the patient's written consent form where the printed drug name appears.
Always contact the prescriber when an order is unclear and make sure you know why a drug is being administered.
Michael R. Cohen is president of the Institute for Safe Medication Practices (ISMP), a nonprofit organization that derives its reports from the USP-ISMP Medication Errors Reporting Program. To report medication errors, call the USP at 1-800-23-ERROR (233-7767). You can reach the ISMP at 215-947-7797 or via e-mail at ismpinfo@ismp.org.
Copyright Springhouse Corporation Mar 2004
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