Multiple Levels Involved in Prescribing the Wrong Medication | PSNet

Multiple Levels Involved in Prescribing the Wrong Medication | PSNet

Multiple Levels Involved in Prescribing the Wrong Medication

This WebM&M case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of physicians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification.