A pregnant lady
walked in a private
pharmacy with a
prescription for *Navidoxine
.The pharmacist
dispensed **Nolvadex
instead?.
After a short time
while the pharmacist
was filing all the
prescriptions for
the day, he caught
the mistake. He
immediately called
the patient who just
reached her house in
Al-Khor city (80 Km
from the pharmacy in
Doha), and explained
to her the mistake.
He sincerely
apologized for what
happened. The
patient told him to
keep it ready and
she was going to
pick it up in later
time.
The Bridge Comment:
The case can be
tackled from many
angles:
First: what are the
drugs used for and
what are the
recommended doses?
Second: what could
happen if a pregnant
lady took tamoxifen?
Third: What is the
ethical dilemma
surrounding a case
like this?
Should we admit our
mistakes or hide
them?
“If you hit someone
with your car, would
you stop or run
away?” If you stop
and help that person
you might save his
life or prevent
complications by
taking proper
measurements like
calling the
ambulance. Are there
any consequences of
stopping? There
might be some
expected
consequences, but
this is what
professionalism is
all about. We must
take responsibility
for our actions, do
right and prevent
harm to others.
Medication
dispensing errors (MDE)
is a global problem.
It might occur in
any setting or by
anyone. No one is
100% immune to it,
and it does not
matter if you’ve
been a pharmacist
for many years or a
new graduate,"To Err
is Human" (3)
To eliminate or
minimize Error: (1)
We should raise the
awareness on the
issue (2) Start
education (3)
Develop a workflow
of double checking
(4) Familiarize
ourselves with the
concept of looks
alike & sounds alike
(5) Doctors should
be advised and
educated on the
importance of
writing legibly and
avoiding confusing
or misleading
abbreviations (6)
Doctors should apply
the safety netting
approach ***"Roger
Neighbour" (7) One
very important
factor in preventing
MDE is patient
counseling, asking
about patient’s
condition and what
the doctor told the
patient about the
medication will
improve their
knowledge about
their medications
and what to expect
from them ect... (8)
Last crucial point
about this case is
having patient’s
phone number. It
should be a routing
practice to have the
contact information
of patients because
it’s related to
patient’s safety,
error prevention and
mitigation and
improving treatment
outcome.
*Navidoxine : Each
tablet contains a
combination of
meclozine 25
mg & Pyridoxine 50 mg which is indicated for the nausea and
vomiting during pregnancy. The usual dose is one tablet
at night.
**Nolvadex is the
brand name of
Tamoxifen. Tamoxifen
is used
mainly for the treatment of breast cancer, anovulatory
infertility the usual dose is 20- 40 mg daily.
***Roger Neibour is
the founder of a
consultation model
that
stresses the use of (what should the patient do if things
doesn’t seem to be doing well ) (4)
Ebrahim Mohammadi,
PharmD,
Sr.Pharmacist ,
Qatar Petroleum, Ras
Laffan Clinic, Doha,
Qatar
