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A medication error
A medication
error Camille A. Servodidio, RN, MPH, CRNO David H. Abramson, MD
A patient had inadvertently
mistaken her son’s diflorasone
diacetate ointment for gen tamicin sulfate ophthalmic
oint-
ment and applied it to her eye in error. A/though no serious consequences resulted from the instillation corticosteroid,
this incident provides another example of
mistaken medication
tubes. (Insight 7996;2 7:49)
A
47-year-old female patient, a contact lens wearer, had an “irritation” in her left eye and was given gentamicin sulfate (Gentak) ophthalmic ointment to use twice daily. Simultaneously, her son was prescribed diflorasone diacetate 0.05% (Psorcon) ointment, a topical corticosteroid, for treatment of dermatitis of his foot.’ While in a hurry one morning, the patient inadvertently placed the Psorcon ointment in her left eye because both tubes had a similar appearance (Figure 1).
Figure
1. Tubes
of the topical
of Centak
and Psorcon
ointment
the left peripheral cornea displayed superficial punctate keratitis or swollen epithelial cells raised slightly above the normal cornea1 surface.’ There were no cells or flare in her anterior chamber. The conjunctiva of the left eye was 3+ injected. Results of the slit-lamp examination of the right eye were normal. The ophthalmologist prescribed sulfacetamide sodium ophthalmic solution loo/o for the left eye, to be applied three times daily for 3 days. The patient was instructed to refrain from wearing her contact lenses during this healing time. To prevent such an incident in the future, the first suggestion is to educate and reinforce to the patient the importance of reading the label on the medication tube. Another suggestion is to put a rubber band around the ophthalmic ointment so that if two tubes were confused, she would notice immediately that she had picked up the incorrect medication. Finally, the patient should keep her medication at a location separate from her son’s medication. Any other suggestions, ophthalmic nurses? References
When she realized the error, she phoned the ophthalmologist’s office immediately and reported directly to the office for an examination. Her visual acuity with glasses was 20/20 in both eyes. On slit-lamp examination, bislciHT
The Journal
of the American
Society
of Ophthalmic
1. Arky R, Rice TF. Physician’s desk reference. Montvale (NJ): Medical Economics Company, 1996:908-9. 2. American Academy of Ophthalmology. Basic and clinical science course: external disease and cornea, section 8. San Francisco: American Academy of Ophthalmology, 1995-199634-7.
Registered
Nurses,
Inc.
Volume
XXI,
Camille Servodidio is a research nurse and lecturer in ophthalmology at the New York HospitalLCornell Medical College and in the private practice of Dr. David Abramson. She joined ASORN in 1988 and serves on the Board of Directors and the Editorial Board. David Abramson is in private medical practice and is a/so a clinical professor in ophthalmology at New York HospitalCornell University Medical College in New York. Reprint requests: Camille A. Servodidio, RN, 70 East 66th St., New York, NY 7 002 1. Copyright 0 1996 by the American Society of Ophthalmic Registered Nurses. 1060-135X/96 72/J/72820
No.
2, June
$5.00
1996
+ 0
49
error Camille A. Servodidio, RN, MPH, CRNO David H. Abramson, MD
A patient had inadvertently
mistaken her son’s diflorasone
diacetate ointment for gen tamicin sulfate ophthalmic
oint-
ment and applied it to her eye in error. A/though no serious consequences resulted from the instillation corticosteroid,
this incident provides another example of
mistaken medication
tubes. (Insight 7996;2 7:49)
A
47-year-old female patient, a contact lens wearer, had an “irritation” in her left eye and was given gentamicin sulfate (Gentak) ophthalmic ointment to use twice daily. Simultaneously, her son was prescribed diflorasone diacetate 0.05% (Psorcon) ointment, a topical corticosteroid, for treatment of dermatitis of his foot.’ While in a hurry one morning, the patient inadvertently placed the Psorcon ointment in her left eye because both tubes had a similar appearance (Figure 1).
Figure
1. Tubes
of the topical
of Centak
and Psorcon
ointment
the left peripheral cornea displayed superficial punctate keratitis or swollen epithelial cells raised slightly above the normal cornea1 surface.’ There were no cells or flare in her anterior chamber. The conjunctiva of the left eye was 3+ injected. Results of the slit-lamp examination of the right eye were normal. The ophthalmologist prescribed sulfacetamide sodium ophthalmic solution loo/o for the left eye, to be applied three times daily for 3 days. The patient was instructed to refrain from wearing her contact lenses during this healing time. To prevent such an incident in the future, the first suggestion is to educate and reinforce to the patient the importance of reading the label on the medication tube. Another suggestion is to put a rubber band around the ophthalmic ointment so that if two tubes were confused, she would notice immediately that she had picked up the incorrect medication. Finally, the patient should keep her medication at a location separate from her son’s medication. Any other suggestions, ophthalmic nurses? References
When she realized the error, she phoned the ophthalmologist’s office immediately and reported directly to the office for an examination. Her visual acuity with glasses was 20/20 in both eyes. On slit-lamp examination, bislciHT
The Journal
of the American
Society
of Ophthalmic
1. Arky R, Rice TF. Physician’s desk reference. Montvale (NJ): Medical Economics Company, 1996:908-9. 2. American Academy of Ophthalmology. Basic and clinical science course: external disease and cornea, section 8. San Francisco: American Academy of Ophthalmology, 1995-199634-7.
Registered
Nurses,
Inc.
Volume
XXI,
Camille Servodidio is a research nurse and lecturer in ophthalmology at the New York HospitalLCornell Medical College and in the private practice of Dr. David Abramson. She joined ASORN in 1988 and serves on the Board of Directors and the Editorial Board. David Abramson is in private medical practice and is a/so a clinical professor in ophthalmology at New York HospitalCornell University Medical College in New York. Reprint requests: Camille A. Servodidio, RN, 70 East 66th St., New York, NY 7 002 1. Copyright 0 1996 by the American Society of Ophthalmic Registered Nurses. 1060-135X/96 72/J/72820
No.
2, June
$5.00
1996
+ 0
49