Pharmacy Preceptors Guild of the Philippines

HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM

CLINICAL PHARMACY – MEDICATION ERROR REPORTING
ACTIVITY ASSIGNMENT – 28

Name of Student: Jonathan B. De Guzman

School: OLFU VAL Section 8

Objective:

● Able to assess and identify medication related error using medication error report form.
● Able to provide appropriate intervention(s) to prevent medication error.
● To enhance the basic knowledge on medication error reporting and promote the culture of
safety.

Case:

Patient is a 71-year-old female, widowed, who was hospitalized for uncontrolled hypertension and acute
kidney injury. During the hospital stay she received temporary hemodialysis, her blood pressure
medications were adjusted, and she subsequently improved clinically. Upon discharge her prescription
medications included Norvasc 10 mg twice daily, metoprolol 50 mg twice daily, doxazosin 2 mg daily, and
torsemide 30 mg daily.

Over the next several months, she began experiencing worsening fatigue, slow movements, personality
changes, and uncontrolled blood pressure. During this time, she was hospitalized once for chest pain and
had several visits to her outpatient family physician where she was diagnosed with anxiety and
depression; for these she was prescribed citalopram and alprazolam. Soon after, she was re-hospitalized
following a fall due to light-headedness.

An admission medication reconciliation revealed that the patient was actually taking Navane
(thiothixene), an antipsychotic, instead of the Norvasc. Upon further review, it was revealed the
pharmacy had accidently dispensed the wrong medication despite the written prescription being fully
legible. After the thiothixene was discontinued, the patient’s clinical status improved. The authors
explain how this example shows the ‘Swiss Cheese Model’ of how medication errors can occur despite
interacting with multiple areas of the health care system.

Instructions:

1. List down all medications prescribed to the patient, indication of each medication and side
effects.

Name of the Indication Side effects Reference*

medication

Amlodipine (Norvasc) For high blood ● Swelling (edema) N.A. (N.D.)

pressure Amlodipine: Generic
● Excess fluid in Drug Retrieved from:

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 Pharmacy Preceptors Guild of the Philippines
HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM
CLINICAL PHARMACY – MEDICATION ERROR REPORTING
ACTIVITY ASSIGNMENT – 28

the lungs https://www.rxlist.co

(pulmonary m/consumer_amlodi
edema) pine_norvasc/drugs-c
ondition.htm
● Headache
● Fatigue
● Palpitations
● Dizziness
● Nausea
● Flushing
● Abdominal pain
● Sleepiness
● Male sexual
disorder
● Drowsiness
● Itching
● Skin rash
● Muscle cramps
● Muscle weakness

Metoprolol For high blood • Tiredness Medline Plus. (2021).

pressure • Depression Metoprolol.
• Nausea Retrieved from
• Dry mouth https://medlineplus.g
• Stomach pain o
• Vomiting v/druginfo/meds/a68
• Gas or bloating 2 864.html
• Heartburn
• Constipation
• Rash or itching
• Cold hands and feet
• Runny nose

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 Pharmacy Preceptors Guild of the Philippines
HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM
CLINICAL PHARMACY – MEDICATION ERROR REPORTING
ACTIVITY ASSIGNMENT – 28

Doxazosin For urinary ● headache MedlinePlus. (2021).

outflow ● tiredness Doxazosin Retrieved
obstruction from:
● swelling of the
https://medlineplus.g
hands, feet, ov/druginfo/meds/a6
ankles, or lower 93045.html
legs
● shortness of
breath
● weight gain
● muscle or joint
pain or weakness
● abnormal vision
● runny nose
● decreased sexual
ability

Torsemide For edema ● Dizziness on Cunha, J. (2021,

standing September 1)
Torsemide Retrieved
● Ear damage from:
(ringing in the https://www.rxlist.co
ears [tinnitus] m/consumer_torsemi
and hearing loss, de_demadex/drugs-c
usually ondition.htm
reversible; avoid
doses greater
than 200 mg)
● Fatigue
● Hyperuricemia
● Itching
● Low back pain
● Muscle cramps

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 Pharmacy Preceptors Guild of the Philippines
HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM
CLINICAL PHARMACY – MEDICATION ERROR REPORTING
ACTIVITY ASSIGNMENT – 28

● Rash

Citalopram For depression ● nausea MedlinePlus. (2021).

● diarrhea Citalopram Retrieved
from:
● constipation
https://medlineplus.g
● vomiting ov/druginfo/meds/a6
● stomach pain 99001.html
● heartburn
● decreased
appetite
● weight loss

Alprazolam For anxiety ● drowsiness. MedlinePlus. (2021).

● light-headedness Alprazolam Retrieved
. from:
● headache. https://medlineplus.g
● tiredness. ov/druginfo/meds/a6
● dizziness. 84001.html
● irritability.
● talkativeness.
● difficulty
concentrating.

Thiothixene (Navane) For Schizophrenia ● dizziness, MedlinePlus. (2021).

lightheadedness, Thiothixene
feeling unsteady, Retrieved from:
or having trouble https://medlineplus.g
keeping your ov/druginfo/meds/a6
balance. 82867.html
● blurred vision.
● dry mouth.
● excess saliva.

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 Pharmacy Preceptors Guild of the Philippines
HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM
CLINICAL PHARMACY – MEDICATION ERROR REPORTING
ACTIVITY ASSIGNMENT – 28

● stuffed nose.
● nausea.
● vomiting.
● constipation.

2. Accomplish the Medication Report Form (Download

https://jipmer.edu.in/sites/default/files/Medication-error-reporting-form.pdf) OR (see separate
file)

3. What type of medication error is based on the case? (Provide reference*)

The preceding scenario involved a pharmacy dispensing error, which could have been caused by
understaffing and the constant pressure to fill prescriptions on time. a solitary person
A pharmacist may be in charge of twice (or more) as many drugs as their technicians.
and it is well known that the length of a shift and the number of patients seen by a pharmacist are
linked.of prescriptions that have been confirmed Pharmacy technicians have a lot of access to
pharmaceuticals and a lot of responsibility.There's a lot of possibility for catching an impending error,
especially when the pharmacist is tired. Apart from it,It's possible that this patient's pharmacy was
understaffed, undertrained, or both.

4. What is your intervention(s) or recommendation(s) to avoid this type of medication error?

To prevent medication error, one solution is to have electronic health records and a computerized
softwares that imports every detail of a patient. This type of advancement will become a huge advantage
to provide more information such as pharmacy location, prescriber identification, date filled, and
directions for administration and drug management of a patient. Also a two-step medication review on
admission and discharge should also be implemented to make sure that all of the documents and data
are correct.

Reference/s:

Da Silva, Brianna A.; Krishnamurthy, Mahesh (2016). The alarming reality of medication error: a patient
case and review of Pennsylvania and National data. Journal of Community Hospital Internal Medicine
Perspectives, 6(4), 31758–. doi:10.3402/jchimp.v6.31758

Tariq, R. A. (2021, May 12). Medication dispensing errors and prevention. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK519065/.

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