October 2004, Volume 34 Number 10 , p 14 - 14
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(10) October 2004 p 14 Subtle sound, big difference [MEDICATION ERRORS: TELEPHONE ORDER]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A hospital pharmacist received an order for a “fentanyl drip, 5,200 mcg per hour,” which a nurse had just transcribed after taking a telephone order. Because this is an extremely high dose, the pharmacist called the nurse to clarify it. She agreed that it was high but said she'd read back the order to the prescriber several times to make sure it was correct. The pharmacist then called the prescriber and learned that the intended order was for a fentanyl drip 50 to 100 mcg per hour.
When reading back a verbal order, confirm the dose by expressing it in single digits, such as 5-2-0-0, to avoid similar errors.