Towards the end of a busy day in his office, a family physician sees a
patient with a known bipolar disorder. The patient’s behavior is
extremely demanding and he repeats his questions several times. The
physician attempts to be as patient as possible but eventually is aware
of becoming increasingly irritated and distracted. Finally, he closes the
encounter by hurriedly writing a prescription for lithium and discharges
the patient from the office.
When the patient presents the script at a pharmacy the following
day, the pharmacist notes that the dose level is written is 3000 mg b.i.d.
rather than 300 mg b.i.d. He telephones the physician’s office to notify
him of the error.
Comment: at the end of a busy day, the physician’s fatigue is
presumably compounded by irritation and distraction. This results in a
failure in concentration that leads to a medication error.