Research PaperDiscuss USP Chapter <797> and the importance of the standards that were created, focus on revisions made in 2008 (include requirements for garbing, environmental quality control, beyond

Preventing Medication Errors in Compounding

Vondra Wesley

Rasmussen College

Author Note

This paper is being submitted on January 1, 2019, for Jessica Howard’s Sterile and Non-Sterile Compounding Course

Preventing Medication Errors in Compounding

In September 2016, A mother and daughter went to a Walgreen’s Pharmacy to pick up her daughters’ prescription for a medication to treat her daughters’ seizures but instead received the wrong medication. After the mother administered the medication to her daughter, she began to notice adverse symptoms appearing in the child. The child was taken to the hospital emergency room where she was admitted and received treatment for an overdose of the incorrect medication. On May 30, the same family went to another Walgreens Pharmacy in another location to get their prescription filled. Upon the mother arriving home, she checked the medication and found that there were two different pills in the bottle. Since then the mother obtained a Lawyer and filed a lawsuit against Walgreen’s accusing them of negligence by failing to take proper care, failing to warn of danger and overall negligence of the employees who filled the prescription incorrectly. (Slappey &amp; Sadd & Slappey &amp; Sadd, 2019) This parent experienced not just one, but maybe two medication errors on behalf of Walgreen’s for a prescription she had received from her daughter's health provider for the treatment of seizures. Had the proper measures and precautions been practiced, this error would have been avoided. It is also essential to focus and pay close attention to detail. Even though the case doesn’t state whether or not this happened due to lack of correct information being processed into the system at the beginning, we must look at all the necessary steps that should have taken place. First, the In-take Technician should have verified all pertinent information about the patient, including reference into any allergies or other medications prescribed to the patient that may cause adverse effects and interactions. Before inputting the prescription information into the system, verify that there are clear and concise understanding and pronunciation and spelling of the name of the medication, administration, dosage. If it’s a weight-based medication, obtain current weight and any other pertinent information. Proceed with the input. Once all information was input into the system, pass all information to the filling technician. The filing technician should review all the information on the prescription and compare it to what was input into the system especially spelling and grammar. If there are any discrepancies or questions, seek the advice of the Pharmacist. Once all is verified as being correct, proceed with retrieving of the medication to fill the order. Compare the name of the medication and the NDC number with the prescription request labels. Once everything passes verification, proceed to fill the medication request and transfer over to the Pharmacist for the final check and verification. According to the second incidence, it doesn’t clearly state if there was a wrong medication provided or changes due to more than one manufacturer such as medication color, texture or shape. In either case, the filling technician should have notified the Pharmacist along with medication packaging and information about the changes. The Pharmacist should have noticed the difference and made necessary corrections and made a special notation in the patient’s profile. In the case of it being two different drug manufacturers but the same drug, the Pharmacist should have given the patient/caretaker informed notice of this event along with any information about adverse effects, drug or food interactions if any, or allergies. Always inform patient/caretaker if they have any concerns, please feel free to ask. Given the completion of this research, I’m more compelled to stay more focused and alert to all pertinent information involving the process of filling medication order requests and the ever-changing status and appearance of medications to ensure the proper care and safety of the patients and the overall well-being of my employment as a professional in Healthcare.

References

Slappey &amp; Sadd, L., & Slappey &amp; Sadd, L. (2019). Walgreen’s Facing Lawsuit After Allegedly Filling Prescriptions Incorrectly. Retrieved from https://www.georgiainjurylawyersblog.net/walgreens-facing-lawsuit-allegedly-filling-prescriptions-incorrectly/