The Pharmacist's Nightmare


by Brent Aleshire, MSW

It was about 3 p.m. when I found out the nursing home staff needed to speak with me right away. They were organizing a new patient's medication and could not read the order sheet. That morning, the patient had been transferred to the facility from the hospital where I was director of Social Services.

Apparently, the nursing staff at the facility could not reach the doctor who wrote the medication orders because he had already left town for the weekend. His associate had not returned their phone calls, and the facility pharmacist wanted to settle the matter before going home.

These calls were not uncommon during my 20 years as a health care social worker. Early on in my career, I wondered how pharmacists could read doctor orders. Often, the handwriting was hard to read at best, and sometimes completely illegible to an "untrained" eye like mine. Nonetheless, orders were processed. Little did I know how many times the pharmacist would call the doctor to clarify orders.

In this particular case, the patient had been at the facility for several hours without receiving medication. Questions arose. Was this a crisis situation? Were there medications that needed to be administered right away? The nursing staff had requested to see copies of the patient's record to review medications that had been given at the hospital, in an effort to "decode" the doctor's illegible orders.

Was the staff overreacting? Take a look at a copy of the actual order http://r.pm0.net/s/c?2p8.7pfc.1.4aa7.aj and ask yourself the following questions: Can you read it? Is there a chance that some of these orders may be misinterpreted? If you were a nurse or pharmacist, would you like to take that chance? If you were the patient, would you be comfortable with this kind of "guessing game?"

This is a dramatic but true example of how accidents can (and do) occur. Unfortunately, it happens all too often. Both pharmacists and doctors agree that drug errors are a problem. As the number of drugs and medications increase, medications with similar names can be mistaken on a prescription.

To ensure your safety, be sure to ask your doctor to carefully review discharge instructions. Also, request written information about all your medications. Review this information with your pharmacist as well.

This story illustrates the importance of staying involved and getting the information you need to avoid this type of "nightmare."



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About the Author

Brent C. Aleshire's goal is to educate consumers so they can confidently approach the health care experience and get the treatment and service they need and deserve.




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