That sinking feeling

Today, I picked up on a prescription where I had made a mistake.

I hate that sinking feeling that you get when a patient rings up to query a medicine they have been given. This involved a lady who had been started on the brand Dilzem in hospital and had continued to be prescribed it on FP10.

The trouble was that the script was written generically with Dilzem in brackets at the end and I had the brand Adizem picked for me. I had obviously seen generic diltiazem on the script, missed the ‘Dilzem’ at the end, seen that Adizem had been picked and assumed that this was the brand that the patient had (I believe this is called ‘root cause analysis’!).

So when the lady rang to query the brand we realised the mistake, swapped it over and apologised to her.

At least this mistake will cause no harm to the patient but we have now tightened up on our dispensing procedure (especially me!) to make sure we triple check scripts for generic diltiazem modified release preparations.