February 2005, Volume 35 Number 2 , p 18 - 18
© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(2) February 2005 p 18 TACtical error [MEDICATION ERRORS: RISKY ABBREVIATION]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A dermatology consultant recommended “TAC 0.1%, apply t.i.d. to affected areas” for a patient with a skin disorder. The patient's primary care provider misinterpreted the recommendation as t etracaine/ a drenaline/ c ocaine and submitted a nonformulary drug request form to get the medication for the patient. The pharmacist intervened and clarified the order with the prescribing dermatologist as triamcinolone cream 0.1%.
A few months later, the same dermatologist wrote the same order for a patient with a rash unresponsive to hydrocortisone cream. A different primary care provider misinterpreted the dermatologist's ...