In Maharashtra, a 10-year-old boy suffering from typhoid was mistakenly prescribed medicines meant for diabetes and heart disease at a Kalyan hospital. Such errors highlight the urgent need for stricter prescription checks and safer hospital practices.
How can hospitals strengthen prescription safety to prevent such dangerous medical errors?
LASA - Look Alike Sound Alike drugs are most coming error in hospital. A systemic arrangement of drugs by alphabetic order or department order could be one of option to reduce error. But 1st and foremost the sop of pharmacy and awareness regarding such drugs is must. Nabh and protocol based system can reduce chances of errors.
Proper prescription writing is a must.Mentioning patient comorbidities on it should be mandatory.At pharmacy too person dispatching the drugs should be aware of contraindications and drug interactions of drugs. If any discrepancy found, or any confusion regarding the drug name, doctor should be informed immediately.
It can be done by writing proper priscription or printing out with proper patient details on it and what is patient suffering from.
Should recheck then send to pharmacy.
After that pharmacy people also check before giving.
And when giving medicine to patinet doctor should check before administrating.
These kind of incidents emphasize the need of additional prescription checks and stricter audit policies. Mandatory mention of diagnosis/indication in the prescription can help a lot (still not followed at many clinics, hospitals in India), double checks for high-risk drugs/patients and regular staff training can help here. Adding PharmDs into care team can be a game-changer as their major role inclines toward catching drug errors and ensuring safer, evidence-based prescribing.
I wish this haven’t happened
A prescription error that put a child at risk was reported in Kalyan. Prescription errors in children are a significant concern as they can lead to serious harm due to factors like individualized dosing based on weight, complex calculations, and drug formulations specific to pediatrics. Such errors often arise from miscalculations, incorrect dose adjustments, or communication issues, and can result in overdosing or underdosing, both of which pose health risks. In pediatric care, the need for precise dosing makes these errors particularly dangerous, underlining the importance of careful prescription review and awareness to prevent harm to children.
I feel once medicine are bought, Dr. Should check medicines and the patient and family too for safety once cross check the medicine are for the same reason or not
Hospitals can strengthen prescription safety by adopting electronic prescribing, regular medication audits, clinical pharmacist involvement in rounds, and clear communication between healthcare teams. Even small steps in system checks can prevent big errors.
A second check can be done as a mandatory part.
I think they should have recheck the prescribed medicine
The should be double check or the prescription written and medicines gives both should be rechecked and proper training of the prescriber and the pharmacist should be done.
Prescription errors can have life-threatening consequences, especially in children who are more vulnerable to dosing mistakes. The Kalyan incident highlights the urgent need for stricter prescription protocols, better pharmacist-doctor communication, and awareness among parents to double-check medications before administration. Patient safety must always remain the top priority.