Ask one more question

Medication errors can happen anywhere at any time. One simple way to help prevent them from happening is to ask questions.

I was working at a retail pharmacy during a busy afternoon. We received a prescription for once daily 1000 mg metformin but the insurance would not cover it, so the pharmacist asked me to call the prescriber and ask if we could dispense metformin 500 mg twice daily.

Tripping Yourself Up

One of the most impactful medication errors that I witnessed was the first medication error where I did not catch my own mistake.

I was working in the inpatient pharmacy on a weekend. We were short staffed and I was running around the hospital like the Road Runner from the Looney Tunes. On my way from one unit of the hospital, I stopped in the pharmacy before heading to the next unit. The pharmacist was having trouble finding a certain medication, so I thought I would try to be helpful and found, what I thought to be, the right medication.

Making it Safe

It was a normal day in the retail pharmacy I work in as an intern when a patient came up to drop-off a new prescription from her doctor. I asked about how the patient was doing and how her day was going so far. The patient told me that she was recently diagnosed with bipolar disorder and she was hoping these medications were going to help her. I empathized with her by expressing how overwhelming that must have been for her, and I told her to let me know if she had any questions about the medication because I would be happy to help.

Culture of Safety in the Classroom

The Purdue University College of Pharmacy is dedicated to patient safety both inside and outside of the classroom. Students in the College of Pharmacy are required to take a course on medication safety, and the university is affiliated with a center wholly dedicated to making “safe medication use common practice”. Changes made and advocated for by the center have helped patients and health systems, but what systems can be implemented to help students learn in a safe environment and ease the transition from student pharmacist to licensed practicing pharmacist?

Following Guidelines

Throughout school, we are always taught the “proper” technique or the “correct” way of doing something, which makes sense for the environment we are in. We are taught the best practices for our settings and how to make evidence-based decisions in patient care. We are taught how things should be done and why doing things in the correct way helps prevent patient harm. Then why, in the real world, does this not always happen?

Know Your Numbers

Whether it is survey responses you have been waiting on for weeks or a spreadsheet full of data you requested, your first instinct may be to dive right into drawing conclusions from the numbers.


Although it may be difficult to resist instantly interpreting your long awaited results, there is a crucial step that must come first. You must begin with reviewing the raw data. What are your numbers really showing?

Be Confident and Speak Up

As an APPE student on a solid-organ transplant unit, I was assigned patients to follow throughout the duration of their hospital stay.  One day during the rotation, I was assigned a patient who received a kidney transplant less than a year prior and had been experiencing high CMV viral loads despite the prophylactic treatment following the operation.  The patient was now on the verge of suffering from active CMV complications and was admitted for aggressive treatment of drug-resistant CMV.  After thorough review of current guidelines and drug information, I realized that this

Dig a Little Deeper

It was during a medication reconciliation for one of our surgical patients when I noticed a discrepancy. Her electronic medical record (EMR) showed that she was on “ferrous sulfate 325 mg one tablet by mouth daily.” However, the patient told me that she “took five of the 65 mg iron tablets.” This dose did not sound right to me; the common daily dose of ferrous sulfate is 325 mg, which contains 65 mg of elemental Iron.

How to Accomplish Your 5-Year Plan

Where do you see yourself in 5 years? I am sure most of us have been asked this question at least once. For example, if your answer is “I want to be working as a full time pharmacist, own a home, and adopt a dog in 5 years”, then you have completed the first step towards goal setting. You have identified were you want to be and the next step requires you to assess your current situation to determine what steps you need to take to achieve your end goal.

Don't Assume

A nurse plopped down in the chair next to me with a frustrated look on her face. She needed my help to re-educate a patient. This patient and her spouse, there for support, have been coming into clinic to get her chemotherapy infusions. She is on a specific chemotherapy regimen which involves taking steroids the day before, the day of, and the day after her chemotherapy infusion. Week after week someone educates the patient-spouse pair on the steroids, and week after week the patient returns to clinic without taking them.


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