A Documented Allergy Overlooked
A doctor prescribed Donnatal (hyoscyamine, atropine, scopolamine, and phenobarbital) for a man who was allergic to one of its ingredients, phenobarbital. Donnatal is used to relax the muscles in the bladder and intestines and to reduce stomach acid. The community pharmacy’s computer system issued a warning about the allergy, but the pharmacist missed seeing the message while entering the prescription into the computer. The doctor also overlooked the allergy even though it was documented in the patient’s chart. The error was discovered by the man while reading the pharmacy provided consumer medication information leaflet, which listed phenobarbital as one of the ingredients. The man did not take the Donnatal.
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