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Multiple Safety Checks Missed Resulting in Double-dose Error

Jan 7, 2013

Several months ago I saw a patient with a 15-year history of type 2 diabetes.

He was seeing both a primary care provider and an endocrinologist. On reviewing his medications I realized that he was taking Glucophage XR 750 tid and metformin 1000 bid.

It turned out that he had seen the endocrinologist in the city where he worked and gone to the pharmacy there to have the Glucophage XR filled using his insurance pharmacy card. He had received the prescription for the metformin from his primary care provider, and paid for this at a chain pharmacy near his home, which offered $10 copayments for generic drugs (he stated this was less than his copayment through insurance).

Lesson Learned:

Multiple safety checks had missed this over-dosage of medication. First the patient did not provide an adequate history of his medications to the endocrinologist. All patients should carry an updated medication list with them when they go to their health care providers. There was inadequate communication between the PCP and the endocrinologist, in both directions. Referrals to specialty healthcare providers should include a current medication list, and not depend on patient-provided information. Patients should be encouraged to only fill medications that they take on a regular basis at one pharmacy, or pharmacy chain. In this case the ‘double-dosage’ of metformin would have been picked up by the pharmacy’s computer system and would have averted this problem.

Lastly, it is very important to make sure that you have a complete medication history when you meet with your patients. Sometimes it is effective to ask, “How many pills are you taking in the morning (at lunch, at dinner, at bedtime, etc.)?” If the number of pills doesn’t equal the medications by dose of their reported medication list, it’s time to delve further into the issue.

Laurie Porcaro, RN, CDE 


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