Caution: Telephoned prescriptions may be misheard!

 

Doctors often call new prescriptions into your pharmacy so you do not have to pick up a handwritten prescription. Unfortunately, prescriptions that are communicated orally can be misheard, as in the following example.

A doctor left a message on the pharmacy's voice-mail system prescribing Prozac (fluoxetine) 10 mg daily for his patient. This medicine is used to treat depression. The pharmacist thought the doctor said Prograf (tacrolimus). Prograf is used to prevent rejection of transplanted organs. Fortunately, when the man picked up the medicine, the pharmacist reviewed the prescription with him. The pharmacist stressed the importance of taking the Prograf exactly as prescribed to prevent rejection of his transplanted organ. The man told the pharmacist he never received an organ transplant, and the prescribed medicine was supposed to treat his depression. The pharmacist reviewed the prescription again, realized his mistake, and filled the prescription correctly. Talking to the pharmacist when picking up your prescription can help detect an error.

Created on December 1, 2008

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work