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Over the month of February, UHNews will showcase lessons learned from four recent incidents to communicate how a variety of risks can be avoided. This is the second instalment: Case Study: Right medication, wrong dose

Pills image*Mr. Fred Stone is a transplant patient (*names and locations have been changed to protect the patient privacy) and was on Tacrolimus (a transplant medication), 5-1mg capsules twice a day. On October 10, Fred called the pharmacy to refill his prescription as he required more medication. There were no more repeats so the pharmacist called his physician. The physician verbally gave the order to dispense 5mg capsules and the instructions on the label were to take one capsule twice daily.

Fred took this medication and began to feel unwell. Since it was the change of season, Fred thought nothing of it and took it easy for the next week. Eleven days later, Fred came to the Emergency Department with headache, chest pain, tremor, visual disturbance and elevated creatinine. He was admitted to Cardiology for further investigation. Upon questioning him, it was revealed that he was taking 5 -5mg tablets twice a day rather than 1-5mg tablet twice a day (five times his intended dose). Fred informed the doctor he could not remember being told to take his medication differently.

Lessons learned
For staff:

  • ​Whenever there is a change in prescription (dosage, frequency or strength) ensure the patient is aware and understands the change

For patients:

  • Always check prescription label for dose and frequency when you receive your new medication
  • If your new medication looks different than your previous one speak with the pharmacist prior to taking the new medication
  • If you have any questions about your prescription or the medication you are currently taking, speak with the pharmacist or your health care professional

Have a question about patient safety? Please contact: privacy@uhn.on.ca or riskmanagement@uhn.on.ca

Next week: Part three Losing unencrypted electronic devices.

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