December 2004, Volume 34 Number 12 , p 14 - 14
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(12) December 2004 p 14 “Take my word” [MEDICATION ERRORS: PATIENT INSTRUCTIONS]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
People who take the anticoagulant warfarin may have outpatient blood work, then get instructions to adjust the dosage after the health care provider reviews the international normalized ratio level. One patient who'd previously received instructions on how many 5 mg tablets to take got a call advising him to take 7.5 mg daily. He took seven-and-a-half 5 mg tablets (37.5 mg) for 2 days before the error was discovered. Fortunately, he didn't suffer serious harm.
If you need to call a patient with dosing instructions, always ask him to do the following:
* Retrieve a pen and paper before you give him instructions. ...