THIS week's contributor is John Guy, PDL's Professional Officer - A mishandled hospital discharge: A PDL member recently alerted us to a serious error that occurred on a hospital discharge summary.
A hospital inpatient was discharged to a community pharmacy with a medication prescription which included Caltrate tablets with a dose of 2 tablets three times daily as the parathyroid had been removed.
The community pharmacist dispensing the discharge prescription did not bother to label the calcium tablets as they are unscheduled and orally advised the required dose.
As is often the way with oral instructions as opposed to written ones, the patient forgot the instructed dose and took only one tablet daily which resulted in severe hypocalcaemia and admission to hospital.
The moral of this incident is that it demonstrates that a prudent pharmacist would label items that are not on prescription but having a stated dose. Always provide written instructions to consumers when counselling as distractions and information overload will often result in consumers becoming confused and not absorbing oral instruction.
Dispensing the Caltrate through the pharmacy dispense system would not only have provided a label but it would also create a history for subsequent supplies.
The above article was sent to subscribers in Pharmacy Daily's issue from 01 Jul 19
To see the full newsletter, see the embedded issue below or CLICK HERE to download Pharmacy Daily from 01 Jul 19
