Focus on Error Prevention: Drug Allergies
By Ian Stewart B.Sc.Phm., R.Ph.
Pharmacy computer systems play a key role in identifying potential drug related problems such as the dispensing of an incorrect dose, an inappropriate change in drug therapy, potential drug interactions and contraindications due to patient allergies.
However, an incorrect input by the computer operator can result in the failure of this important safety system.
Case:
Following dental surgery, a patient was prescribed Amoxicillin 500mg to be taken three times daily for one week. The written prescription was taken to a local community pharmacy for processing.
Upon accepting the prescription from the patient, the pharmacy assistant gathered the usual information including possible allergies to medications. The patient indicated that he was severely allergic to penicillin. In response, the pharmacy assistant entered into the patient profile that he was allergic to “Pen”. The prescription was then put aside while the pharmacy assistant served another patient.
A few minutes later, the pharmacy assistant entered the prescription into the computer and failed to identify that Amoxicillin would be contraindicated for a patient who is severely allergy to penicillin. Amoxicillin was therefore prepared to be checked by the pharmacist. The computer alert system did not detect the contraindication because the system did not recognize “Pen” as penicillin. The pharmacist checked the prescription, but did not notice “Pen” listed as an allergy on the patient’s profile.
While counselling the patient, the pharmacist mentioned, “This is Amoxicillin, a penicillin antibiotic”. The patient interrupted the pharmacist and stated that he was severely allergic to penicillin and he had informed the staff when he handed in the prescription.
The patient was not happy that though he informed both the dental office and the pharmacy that he was severely allergic to penicillin, he was still being given penicillin.
Possible Contributing Factors:
The pharmacy assistant used an abbreviated form of the word penicillin which the computer alert system failed to recognize.
- The delay between the prescription being accepted and later entered into the computer may have played a role in the pharmacy assistant’s failure to identify the contraindication.
- The pharmacist failed to notice “Pen” listed as an allergy in the patient profile and therefore did not investigate its meaning.
Recommendations:
- Do not use abbreviations when entering allergy information into patients’ profiles.
- Double check the spelling of the information entered. In another error reported, the computer system failed to detect a patient’s contraindication to taking erythromycin because erythromycin was misspelled when the patient’s allergies were entered into the computer.
- Whenever possible, select the specific drug allergen from a list in the computer. Entering the information in freeform can introduce errors.
- Be careful when selecting the specific allergen. Remember that sulfur is not the same as sulfonamide. Therefore, if sulfur is entered into the patient’s profile as an allergen, the computer system will not prevent the dispensing of sulfa drugs such as sulfamethoxazole.
Please continue to send reports of medication errors in confidence to Ian Stewart at:
[email protected].
Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.