Nursing Report 6 February, 2007

Roosevelt Hospital

Main Pharmacy

At and around 4:00PM on the 5^th of February the Pharmacy was called by the an unidentified nurse who stated she was from the Emergency Room. The nurse said that she they have an order for Ceftriaxone 250mg IM and that she went to the Pixus system to get the does and received a 1g vial. Since historically ceftriaxone comes more cost effectively in 1g vial, and since the staff is blind to how the pixus system is filled, I told her not to worry, that the drug was not expensive and to draw 250mg from the vial and not to worry about the waste. The nurse then said, “but it is a 1g vial”, so I repeated that she shouldn't stress over it and over use 250mg of the 1g vial. She repeated words again exactly a third time. Reaching an impasse in communicating with her, I thought I must not be understanding what was distressing her. I asked her if she was a new employee or familiar with the pixus. First she said she was new, and then she changed her mind and said she wasn't new and was familiar with familiar with our pixus. I said that's good. So then what is the pixus labeled for. And only then she explained that the pixus is labeled for 250mg vial, but instead had 1g vials in the 250mg slot. That was completely different than her previous description that she had an order for 250mg and the pixus dispensing a 1 gram dose. The first is a mislabeling problem and the second is a common occurrence within the hospital, even without pixus. After she made it clear that the pixus was designated to be filled with 250mg vials, and instead was filled with 1g vials, I told her that was a big problem and I would dispatch someone to fix it right away. I sent a Pharmacy technician to the ER to confirm the error and to repair it. I then went to Pharmacy Director to ask if I should make a follow up report. The director instructed me to have the Pharmacy Inpatient Supervisor to make an incident report. I followed those instructions.

At about 5:00PM we then received a nursing report on the incident. This report is my follow up to that nursing report and will hopefully clarify any miscommunication which might have been involved.

To reiterate, immediately upon receiving a report from the Emergency Room nurse that we might have mislabeled drugs in the Emergency Room, something that was not initially clear at the start of the conversation, specifically that Ceftriaxone 1g vials were placed in a Pixus location which is designated and identified at dispensing as a 250mg vial, I instructed our staff to correct the problem, which they did immediately. In addition, I specifically informed the nurse making the report that this mislabeling was an important problem which I would immediately remedy. And finally, I reported the problem to our supervisory staff to file proper reports in order to evaluate the error and to begin the processes of making corrections in procedures as might be necessary in order to prevent such an error from happening again.

Ruben Safir RPh Staff Pharmacist