WHEN IN DOUBT, CLARIFY 


 It’s amazing how something this small can snowball.  A pharmacy vendor for a long-term care facility received an order for potassium chloride (KCl) solution 10 mEq/15 mL with a dose of 10 mEq once daily.  KCl solution is commercially available only in a strength of 20 mEq/15 mL.  The pharmacy never clarified the order but instead, dispensed the 20 mEq/15 mL solution and labeled the bottle “10 mEq=7.5 mL”, which would have yielded the desired dose.  During their annual visit, the Department of Public Health noted the disconnect between what was written in the physician’s order section, the medication administration record, and what the pharmacy dispensed and labeled.  The good news was the disconnect did not result in patient harm because the correct dose was on the label.  The bad news was the error triggered an expanded investigation which uncovered numerous serious, possibly life-threatening, medication issues.   As a result, the facility received an immediate jeopardy (IJ) citation and a significant fine and subsequently incurred even more legal fees when they fought (unsuccessfully) the citation.  The pharmacy vendor, who started the chain of events, was rightfully terminated from a potentially lucrative contract.  For any long-term care pharmacy who finds themselves in this situation, always clarify (and document) even if you know already what the answer is going to be.

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