Ian Stewart, B.Sc.Phm., R.Ph.
Effective communication between physicians and pharmacists is critical to ensure optimal patient outcomes.
However, prescriptions given verbally by telephone are prone to errors due to potential verbal miscommunication and/or transcribing errors.
Contributing factors for verbal miscommunication may include background noise, being rushed, sound-alike drug or patient names, similar sounding numbers like fifteen versus fifty. Other factors, such as the speaker’s accent or a hearing impairment could influence communication effectiveness and it’s important to consider these respectfully.
Pharmacists and pharmacy technicians must also be aware of the potential for the inadvertent interchange of milligram and milliliter.
Case:
A cardiologist telephoned a community pharmacy to provide a verbal prescription for an infant.
The pharmacist wrote the verbal order as:
Rx:
Nadolol 10mg/ml
Sig: 5mls twice daily for 30 days
The pharmacist read the prescription back to the cardiologist who “okayed” the prescription. The pharmacist also enquired whether Nadolol is to be added to the Sotalol which the patient was currently taking. The physician confirmed that the patient should indeed take both Sotalol and Nadolol.
During the next shift, another pharmacist who was concerned also contacted the doctor by telephone to confirm the dose of Nadolol and whether it should be added to Sotalol.
The pharmacist recalled that a “very angry” physician called back to confirm that the prescription was indeed okay to dispense.
Upon pick up, the pharmacist informed the child’s father that the dose of Nadolol is unusual. They also mentioned that it is peculiar that Nadolol is given together with Sotalol.
The father responded that he is aware that Nadolol should be added to Sotalol, and his wife is aware of the dose. The pharmacist therefore dispensed Nadolol with the instructions to give 5mls twice daily.
The infant’s mother became alarmed when she observed her husband withdrawing 5mls as she had been advised to give a lessor amount. She therefore contacted the cardiologist to confirm the dose.
The cardiologist advised that he had prescribed 5mg (not 5mls) to be given twice daily.
The error would have resulted in the infant receiving 50mg Nadolol twice daily or ten times the prescribed dose.
Possible Contributing Factors:
- Failed communication between the pharmacist and physician.
- The pharmacist failed to appropriately assess the verbal prescription by gathering the infant’s weight and the indication for use, and then using this information to calculate the recommended dosage.
- When speaking with the physician about the verbal prescription, the pharmacist failed to clearly articulate their concern for potential drug-related problems (e.g., dose too high, duplication of therapy).
- Confirmation bias between the pharmacist and physician when clarifying the verbal prescription, such as not verifying the prescribed dose in milligrams (mg) against the: drug’s concentration (mg/mL), volume to be administered (mL), and total quantity authorized
Recommendations:
- When taking verbal prescriptions, always take the time to read back to the prescriber, to confirm your understanding of their intent.
- If there is a concern or uncertainty with the prescription, follow up with the prescriber to ensure you understood it correctly.
- All drug therapy must be assessed for appropriateness. Factors to be considered include the patient characteristics, medication history, current therapy, indication for use, dose, dosing interval and duration of therapy.
- Use open-ended questions to gather required information including the indication for use and weight for all pediatric patients.
- The child’s weight, the indication for use and recommended dosage regimen should always be used to ensure pediatric doses are appropriate as these patients are at an increased risk of experiencing harm.
- Wherever possible, a second individual should independently complete the calculation without prior knowledge of the results of the first calculation.
- If there are any concerns regarding the prescribed therapy, clearly articulate your concern (ideally in writing) by specifying both the prescribed and recommended dose and/or dosing interval.
- Be aware of the potential for hesitancy in contacting prescribers who may be perceived as impatient or intimidating.
Please continue to send reports of medication errors in confidence to Ian Stewart at: ian.stewart2@rogers.com . Sharing your experience can prevent similar occurrences at other practice sites.
Please ensure that all identifying information (e.g., patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.
- Anonymously record all medication incidents and good catches (near misses) via the AIMS medication event reporting platform.
- Document appropriate details of medication incidents and good catches in a timely manner to support accuracy.
- Analyze the incident in a timely manner for causal factors and commit to taking appropriate steps to minimize the likelihood of recurrence of the incident.
- Promptly communicate the appropriate details of a medication incident or good catch, including causal factors and actions taken as a result, to all staff.