/publications/issue/2003/2003-08/2003-08-7328

August 2003: Case Study 2

Author: Dawn Reser of Iowa Lutheran Hospital in Des Moines, Iowa

The number of prescriptions received at hospital pharmacies in a day is staggering. Therefore, poorly written prescriptions take up a pharmacist?s valuable time and can lead to medication errors. This is exactly what happened with these prescriptions. Registered Pharmacist Dawn Reser of Iowa Lutheran Hospital in Des Moines, Iowa, received these prescriptions for the same patient on 3 consecutive days. The physician?s illegible handwriting led to a prescription error. Do you know what medications the physician ordered?

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1. Furosemide 20 mg IV now and daily
2. Torsemide 40 mg po daily [interpreted by pharmacy as Furosemide]
3. D/C Furosemide 40 mg po Torsemide 40 mg was ordered