Lisa Oliveras
Pharmacy Technician
MidState Medical Center
What happened:
Lisa was pulling medication to refill the dispensing machines used throughout MidState Medical Center when she noticed the 100 mg capsules of certain anticonvulsant drugs looked larger than normal. She immediately notified the pharmacist, who confirmed that these 300-mg capsules had been mistakenly marked as 100 mg. Some of the packages already had been placed in the machines, but Lisa’s quick action meant that none of the mislabeled medications were given to patients.
Safety behaviors demonstrated:
Lisa’s questioning attitude, close attention to detail and clear communication prevented patients from getting the wrong dose.
