Near-disasters from the front lines of pharmacy care

Collard greens and one little zero can kill

These are real situations, as experienced by a clinical pharmacist. All are avoidable, potentially dangerous…and occasionally have a wryly amusing twist:

  1. An airline pilot who hadn’t taken any opioids came in with a prescription for fentanyl patches because his dentist thought it would be a safer choice for post-op dental pain since it was topical. This is outrageous, because fentanyl is only safe for patients who’ve been taking a minimum of 60mg of morphine daily (or its equivalent) for at least two weeks. Fentanyl is never appropriate as a post-op medication for pain relief for a patient who’s not currently taking an opioid at the above-dose minimum. Also, pilots are prohibited by law from taking opioids (among other things) and could lose their license for doing so. Needless to say, the pilot was very grateful that I took the time to explain all of the above, as he had tried to fill it at other pharmacies and been turned away without an explanation. Now he knew!
  2. A patient being seen in an anticoagulation clinic couldn’t get her warfarin dose to target. No matter how the clinic adjusted the dose, her test was coming back looking as if she weren’t taking any warfarin. She swore she was taking the medication. She’d been educated on how diet and vitamin K affect warfarin, specifically green, leafy veggies. The clinical pharmacist eventually discovered that the patient had been cooking collard greens for her family. Since she knew she wasn’t supposed to be eating them, she was drinking the pot liquor instead. That’s right…she was drinking the water they’d been boiled in — the extracted, concentrated vitamin K!
  3. An elderly patient who had difficulty swallowing had been receiving oral morphine liquid 10mg/5ml to treat her pain. She was seen by a different doctor who was trying to do her a favor and renew her prescription, but accidentally wrote for the oral morphine liquid 100mg/5ml strength. The pharmacist caught the error prior to dispensing and had the Rx changed by the prescriber. A 10x unintentional dose increase would have very likely killed her!

I’ll share more stories from the front lines of pharmacy care from time to time. But know that the RxLive® clinical pharmacists are here to help patients, providers and even payers avoid medication errors due to a disconnect across a patient’s prescribers, the person’s OTC meds and supplements and, like the collard greens, foods that can negatively impact the desired effect of a total medication regimen. As we say, “it’s good to check your meds”. And we’re always here to help do so.

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You may also want to check out the following:

How Pharmacists And Pharmacogenomics Can Shorten Your Medication Prescribing ‘Odyssey’ And Improve Your Patients’ Health

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Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.