Prescription Safety

We found out from the doctor that my infant has an ear infection again. She seems to always get them so this is our third trip to the pharmacy in the last couple months. The doctor called in the prescription in the morning and I went to pick it up in the evening after work. My infant and I were there together, I was holding her on my hip because she's not walking yet. When we arrived the line was probably ten people deep, something that I've experienced before at this pharmacy. It was about fifteen minutes until we got to the front of the line for pick-up. I think someone should create a vending machine for frequently prescribed low-risk drugs and leave the personal interaction to the more complicated situations.

At the front of the line, I told the cashier my daughter's name and she couldn't find her prescription so then I had to wait for the ONE Pharmacist on duty. Another half an hour later, we find out that her prescription was flagged earlier by the prior Pharmacist on duty because the dosage prescribed by the doctor was double what is recommended. For someone like me who is curious about healthcare process and systems, this was interesting to me. I had not experienced this type of feedback before. The Pharmacist said it would probably be another half hour while she checks with my daughter's doctor. At this point, it was 45 minutes since we arrived to the pharmacy and my daughter was getting impatient so we left and I would come back later.

When I went back later to pick up the prescription, of course I had so many questions. How did the Pharmacist know it was double the dosage? Did the computer tell her that? I did ask the questions and the answer was, they have a manual process where they check the appropriateness for all prescription for children under one years old. They do have a system that checks the appropriateness of some prescriptions, but this did not fall into that category. The Pharmacist did get ahold of the doctor and confirmed the original dosage was incorrect and modified it. I was so happy that they identified this conflict since it wasn't safe for my baby. I was so happy and the Pharmacist too seemed beaming that she could help.

Bringing this post back to Technology. I was surprised that this wasn't caught by any system either at the Physician's end when writing the prescription or at the Pharmacy. Patient safety is critical and risky for health businesses if prescriptions are not appropriate for the patient. I am extremely grateful that through human review this error was found. However, this is a scenario that I think needs to be more protective to patients by the use of technology. We should be integrating tools like prescription screeners to improve patient safety.