August 2004, Volume 34 Number 8 , p 14 - 14
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(8) August 2004 p 14 15 or 50? [MEDICATION ERRORS: TELEPHONE ORDER]
COHEN, MICHAEL R. RPH, MS, ScD
A nurse working the night shift in the ventilator unit of a long-term-care facility contacted the on-call pharmacist with a new order for 50 mEq of potassium phosphate I.V. “now.” When the pharmacist questioned the excessive dose, the nurse said she was sure the prescriber had ordered that much. Aware that misunderstood orders for phosphate salts can lead to dangerous errors, especially when orders are given over the phone, the pharmacist insisted that the nurse verify the dose with the prescriber. When the nurse called the prescriber, she learned that he'd ordered a 15 mEq dose.
Always transcribe verbal orders on the patient's medication order form (not scrap paper). Read back all oral orders, ...