Read The Case Study Below And Then Respond To Questions

Read The Case Study Below And Then Respond To the Questions That Foll

Read the case study below, and then respond to the questions that follow. A pharmacy technician asks the pharmacist if it's suitable to substitute Fiorinal No. 3® for Sedapap®, which was prescribed, because of the nearly identical chemical properties of the two drugs. He explains to the pharmacist that the pharmacy is out of Sedapap and that the prescribing physician did indicate that a suitable substitution medication was allowed. The pharmacy technician fills the order, substituting Fiorinal No. 3® for Sedapap®. The patient takes the Fiorinal No. 3® and is hospitalized after going into anaphylactic shock. Fiorinal No. 3® contains codeine, which the patient is allergic to.

The pharmacy technician later finds out that Fiorinal No. 3®, a Schedule III drug because of its codeine content, is vastly different than the drug simply referred to as Fiorinal®, a non-narcotic agonist analgesic.

Question 1: Is this error the fault of the pharmacy technician only? Why or why not?

The error cannot be attributed solely to the pharmacy technician, although his actions significantly contributed to the adverse outcome. The technician’s decision to substitute Fiorinal No. 3® for Sedapap® was influenced by multiple factors, including the pharmacist’s previous assurance that substitution was permissible and the medication shortage. However, the technician bears responsibility for ensuring that any substitution is safe, appropriate, and explicitly approved by the prescribing physician, especially when the medications are not therapeutically equivalent. The technician’s failure to verify the medication’s identity and to assess the patient’s allergy history highlights the importance of thorough medication reconciliation and verification protocols. Nonetheless, the pharmacist also shares responsibility in ensuring that the substituted medication is appropriate and clearly documented, particularly given the significant difference in drug classification and potential for harm. Therefore, while the technician played a key role, the fault is shared among multiple levels of the healthcare and pharmacy team for inadequate communication and verification.

Question 2: Is it the fault of the physician?

The physician’s role in this incident appears limited, as the prescriber authorized that a substitution was permitted, and there was no indication of intent to prescribe Fiorinal No. 3®. The primary responsibility of the physician is to provide clear and precise prescriptions, including explicit instructions regarding allowable substitutions and awareness of the patient’s allergy profile. In this case, the prescribing physician did indicate that a substitution was acceptable, which may have influenced the pharmacy’s decision to proceed. However, the physician did not specify which medication was appropriate or confirm the substitution’s safety concerning the patient’s allergy status. The fault, therefore, appears more rooted in pharmacy practice and communication rather than solely the physician’s mistake. If the physician had explicitly contraindicated certain substitutions or provided detailed instructions emphasizing medication identity and patient allergies, it might have mitigated the risk. Overall, the physician bears minimal fault but shares some responsibility in clear prescription writing and communication regarding medication substitution.

Question 3: What are the potential outcomes of this error?

The most immediate and severe outcome was the patient experiencing anaphylactic shock after taking Fiorinal No. 3®, which contains codeine—a substance to which the patient was allergic. This adverse reaction could have resulted in respiratory failure, cardiovascular collapse, and potentially death if not promptly managed. Beyond the acute event, this mistake undermines patient safety and trust in the pharmacy system, emphasizing the critical importance of medication verification processes. Long-term consequences may include legal ramifications for the pharmacy and healthcare providers, increased scrutiny of medication substitution protocols, and potential reputational damage. Moreover, the incident underscores the risks associated with medication errors, especially involving controlled substances and patients with known allergies, highlighting the need for rigorous checks and effective communication among healthcare professionals to prevent similar incidents in the future. It also accentuates the importance of patient education about medication allergies and encouraging patients to verify their medications.

References

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