Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Publication Type: Note Messages
Single or Multiple Incident: Multiple
Date: 7/28/2020 12:00:00 AM
Country: Denmark
This alert discusses the potential and actual risk of a medication error due to a drug shortage. Digoxin 250 micrograms had been backordered. It was necessary to substitute Digoxin 250 micrograms with 4 tablets of 62.5 micrograms. However, a miscalculation can lead to an increased risk of incorrect dosing. One case of digoxin toxicity is described. Recommendations for the prescribers as well as dispensers and those administering digoxin are provided.

Additional Details

Medication/Gas/Fluid:
digoxin oral

Rules / Policies / Procedures
  1. It is important that you as a doctor, if a patient's tablet strength is to be changed, create a new prescription in FMK, so that the strength and number of tablets of the prescribed medicine and the dispensed medicine match.
  2. As a prescribing doctor, you can create a dosage in several ways in FMK. The safest solution in relation to the prescribed dosage being clear when transferring to local medication lists at eg nursing homes, is that you use structured dosage in FMK. If you choose dosing as free text in FMK, the risk of errors increases when the prescription is transferred to the local medicine lists.
  3. There must be consistency between the medication prescribed by the doctor in FMK and the medication that appears on the local medication lists. In the coming time, have extra focus on whether there have been changes in the Digoxin treatment during the transfer from FMK, and also pay extra attention to the strength and number of tablets in the dispensing and administration of Digoxin, so that it is ensured that the patient receives the correct treatment.

Risk of incorrect dosing due to backorder of Digoxin 250 micrograms