Fall 2019, Focus on Error Prevention

Focus on Error Prevention (Fall 2019)

Banner Fall 2019 - Focus On Error Prevention - Prescription
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By Ian Stewart R.Ph, B.Sc.Phm.

Pharmaceutical manufacturers often create line extensions of brand name products to provide new strengths and delivery mechanisms. Though these XR, LA, CD, SR, XL, MR, ER, and CR products may increase adherence, their similarity to the original product may be a contributing factor to medication errors. Proper assessment is necessary to ensure that the patient receives the correct drug and dose.


Focus Error Prevention - Prescription Fall 2019

A sixty-one year old patient took the above prescription to his usual community pharmacy for processing.

Diamicron® MR was dispensed as prescribed. However, Janumet® XR 50mg/1000mg was dispensed as Janumet® 50mg/1000mg. The patient took two tablets at bedtime as instructed.

Three months later, the patient returned to the pharmacy with another prescription for Janumet® XR 50mg/1000mg. On this occasion, the correct medication was dispensed.

The pharmacist initially thought that there was a change in the prescribed medication. However, upon reviewing the previous prescription, the error was identified.


  • The physician wrote “XR” between the two drugs and it was therefore missed.
  • The pharmacist failed to note that Janumet® is usually taken twice daily while Janumet® XR is usually taken once daily.
  • It appears that counselling did not take place as no documentation took place.


  • When dispensing medications, always assess the appropriateness of the drug therapy. Factors to be considered include the patient parameters, medication history, indication for use, the dose, dosing interval, duration of therapy, etc. In the above example, is Janumet® 50mg/1000mg taken once daily appropriate? Also, is Diamicron® MR taken twice daily appropriate as it could put the patient at risk of nocturnal hypoglycemia?The prescriber should always be consulted to discuss any discrepancies.
  • Always check the patient’s medication profile to identify prior and current medication use when dispensing both new and refill medications.
  • Ensure the patient receives appropriate counselling. If counselling did not take place, document a valid reason for not providing it.
  • Use caution when dispensing pharmaceuticals with line extensions to ensure the correct product is dispensed.

These include, but are not limited to:

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.

Registrants are reminded that as part of the AIMS program, they must:

  • Anonymously record all medication incidents and near misses via the AIMS medication event reporting platform.
  • Document appropriate details of medication incidents and near misses 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 near miss, including causal factors and actions taken as a result, to all staff.

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