Do you take the time to double check the medications that your pharmacy has dispensed?

If you’re like many people, you just assume the pharmacist knows what they are doing – after all, they are a highly trained professional - and has given you the right medication, properly dosed. You may want to reconsider that assumption in the future.

Founder, retired,
Eldercare Home Health Inc.

Wrong syringe provided by pharmacy Wrong syringe provided by pharmacy


Hydromorphone is an opioid that is 5 – 7 times more potent than morphine. It’s used to treat moderate to severe pain. As noted on the website CMAJ Open, published by the Canadian Medical Association, Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. Of the 8 cases noted in the article that resulted in death, 5 involved dispensing errors.

Palliative care client prescribed Hydromorphone

Our Eldercare Home Health Nurse was visiting an elderly client. The purpose of the Nurse visit was to provide an initial assessment as the Client had just come on service. The client was at home and required palliative care. A doctor from the palliative outreach team had ordered Hydromorphone to provide pain relief.

A note about our nursing assessment

When we take on new clients, we always provide a nursing assessment. This assessment is always provided by a Nurse.

It is our opinion that only a Nurse is qualified to provide the assessment of an elderly person’s care needs. Our experienced Nurses know what to look for, what questions to ask and what the red flags are.

Other home care services in Toronto will often send someone they call a care planner, care designer, or care co-ordinator. Do not be fooled. Learn more about the Eldercare Home Health nursing assessment

An important part of the initial assessment is reviewing the client’s medications.

The Nurse looks for obvious things like expired medications, but is also on the alert for inconsistencies between, for example, what the family Doctor has prescribed and what the Hospital has prescribed.

The Nurse is also assessing how the medications have been dispensed – in the case of pills and caplets, are they in individual bottles, in a dosette (plastic containers with multiple compartments for different days/times), or have they been blister packed by the pharmacy.

Attentive, experienced Nurse prevents a tragedy.

Which brings us back to our client’s situation.

The Doctor had ordered Hydromorphone liquid, .3ml to be administered by mouth every hour as required. The Pharmacist who filled the prescription had provided a bottle of hydromorphone liquid and a syringe to be used to draw up the medication – see photo below.

The prescribed amount was .3 ml – point 3 mil

Looking at the syringe that the pharmacist had provided, you might think that you should fill it to the point indicated on the top, larger syringe.

Side by side of syringe pharmacy provided and correct syringe our nurse sourced

Side by side of the wrong syringe (top) the pharmacy provided and correct syringe (bottom) our nurse, providing our nursing assessment, sourced

You may be surprised to learn that you would have overdosed the client by a factor of 10 if you had.

In fact, it is almost impossible to draw .3ml of medication using the syringe the pharmacist had provided.

Fortunately for our client, our Nurse had identified this critical error.

She phoned the pharmacist who had dispensed our client’s medication and requested appropriate syringes with which she could draw up the prescribed dose, and was told they didn’t have any.

She called several other pharmacies and received the same answer.

Finally, she located the correct syringe  – the smaller syringe below the large one, in the photo – at the outlet of one of our trusted suppliers of medical supplies

She hopped in her car, picked up the syringes, then spent an additional hour loading them all so that they would be on hand when the client needed them (loading syringes is not within the scope of practice for PSW caregivers).

An afternoon appointment that under normal circumstances would have lasted about an hour, turned into four-and-a-half-hour visit and a very long day for our Nurse Case Manager. But, most importantly, our client had their medication safely and accurately loaded, and available .

So, what’s the takeaway here?

First and foremost, the assessment and actions of our experienced Nurse Case Manager avoided what could easily have turned into an overdose tragedy – a 10-fold excessive dose of a powerful narcotic, being administered in error to a frail older adult.

Secondly, this situation highlights why at Eldercare Home Health, initial assessments are always conducted by a Nurse.

And this is just one example of the vital role our Nurses play in the care of our clients. Our Nurses oversee the care of our clients on all levels. From the initial nursing assessment, to reviewing medications. From determining the plan of care to supervising the staff and addressing unexpected issues. And of course, advocating for our clients.

If you have an elderly family member who needs care. Call us. We’re here to help!

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