July ⢠August 2003 - Ontario College of Pharmacists
July ⢠August 2003 - Ontario College of Pharmacists
July ⢠August 2003 - Ontario College of Pharmacists
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COLUMN<br />
F O C U S<br />
O N<br />
Error Prevention<br />
Counselling Patients on Pre<br />
brand <strong>of</strong> the drug. The tablets were therefore labelled<br />
NovoPurol® 100mg. The following day, Mr. Smith<br />
continued to take his regular medication including Apo<br />
Allopurinol 100mg along with what he believed to be a new<br />
drug NovoPurol® 100mg.<br />
Ian Stewart, B.Sc.Phm.<br />
Though the pharmacist may dispense the right drug at<br />
the right dosage, patient education is critical in<br />
ensuring that the right patient takes the right dosage<br />
<strong>of</strong> the right drug at the right interval. As the following cases<br />
illustrate, lack <strong>of</strong> patient education may lead to drug administration<br />
errors.<br />
CASE 1<br />
Mr. Smith, a 70-year-old patient, regularly takes the<br />
following medications.<br />
Drug<br />
Apo Allopurinol 100mg<br />
Avapro® 150mg<br />
Apo Atenolol 50mg<br />
Dose<br />
Once daily<br />
Once daily<br />
Once daily<br />
Recently, Mr. Smith received a new three-month<br />
prescription <strong>of</strong> Allopurinol 100mg from his physician. On<br />
this occasion, the pharmacist dispensed the Novopharm<br />
A few days later, Mr. Smith requested a refill <strong>of</strong> his Apo<br />
Allopurinol 100mg tablets. On questioning the patient<br />
regarding the need for an early refill, the pharmacist learned<br />
<strong>of</strong> the misunderstanding and as a result, the doubling <strong>of</strong> the<br />
prescribed dosage <strong>of</strong> Allopurinol.<br />
Possible Contributing Factors:<br />
• The patient was unaware <strong>of</strong> the relationship between Apo<br />
Allopurinol and NovoPurol®<br />
• The patient did not question the physician or the pharmacist<br />
regarding his ‘new’ therapy<br />
• Appropriate counselling did not take place when NovoPurol®<br />
was dispensed<br />
Recommendations:<br />
• Always review the patient’s medication history prior to<br />
counselling<br />
• Educate your patients regarding the relationship between<br />
brand names and generic names — this is especially<br />
important when switching brands. In these instances,<br />
place a sticker or note on the prescription bag to remind<br />
the pharmacist/yourself <strong>of</strong> the need to counsel the patient<br />
• Encourage your patients to ask questions, especially when<br />
they notice something different about their prescription/medication<br />
38<br />
Pharmacy Connection <strong>July</strong> • <strong>August</strong> <strong>2003</strong>