MEDICATION ERRORS: Well…what'll it be?

June 2004 
Volume 34  Number 6
Pages 18 - 18
  PDF Version Available!


  • Teach patients to “think it through”

    Twice in 1 week, a psychiatrist ordered the antidepressant Wellbutrin XL (bupropion extendedrelease, once-a-day formulation), 300 mg, for a patient, but each time two tablets of Wellbutrin SR (bupropion sustained-release), 150 mg, were dispensed. The hospital pharmacists weren't aware of the XL formulation, which was new at the time, and “XL” wasn't clearly written in the order.

    In another case, a prescriber ordered “Wellbutrin XR ,” 150 mg daily, although no such product exists. Only Wellbutrin XL is formulated for daily dosing. The pharmacist reviewed the patient profile and found that the patient had, in fact, been taking Wellbutrin SR once daily. The prescriber had intended the XL formulation, but Wellbutrin SR was dispensed for the patient.

    Verify all new orders for Wellbutrin if you have any doubt about the intended formulation or the recommended dosing schedule. ...

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