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Pharmacy's role in prescription error

Regarding the letters on the poor prescribing regimes for patients discharged from hospital (Letters, January 5), the hospital pharmacy is not always the safeguard it ought to be.

My mother was discharged from a major city hospital in central Scotland on Spironolactone. The label on the box supplied by the hospital pharmacy stated clearly Spironolactone 25mg tabs 1 tab once per day. The label had been superimposed on a box of 100mg Spironolactone tablets, and the tablets inside were indeed 100mg tablets.

Her discharge from hospital had been delayed a few days because of renal impairment following initiation of an ACE inhibitor. As she was due to see her GP over a week after discharge she continued on quadruple dosage of Spironolactone for one week until I visited her and asked to see her box of tablets.

Dr D Boyd


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