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Tramadol Nightmares

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I never thought that tramadol being a schedule 3 controlled drug would become such a problem. Sure, I envisioned doctors forgetting to fill out controlled drug discharge forms (as is needed for other CDs) and us having to remind them. Or outpatient prescriptions from A&E and clinics coming through without the total quantity in words and figures. However, I forgot totally about the aspect of storage and the CD register (because my trust, like many others, requires safe storage of most schedule 3 drugs). Until it became very problematic this week.

The day before tramadol became a CD, the ward pharmacy technicians moved all patients’ own tramadol into the CD cupboard and entered them into the CD register on all hospital wards. Having already sorted out a quantity discrepancy just a few days after the legislation change last week, I was faced with another more complex one this week on the same ward.

The minute I walked onto the ward, the ward sister said “Sadia!” with a beam on her face. I thought she was just happy to see me, but on seeing her stood by an open CD register I found out it was more relief than happiness.

It looked as though a patient that had been prescribed tramadol M/R had been given tramadol immediate release instead of tramadol M/R, because the amount of the former was down and the amount of the latter was up, but by more than it should have been. To complicate things further, the tramadol M/R stocked on the ward was the 100mg strength, meaning the wrong dose may have been given at some point too.

After ten minutes of trying to work out how the quantities ended up as they were, I gave up and asked for another pair of eyes in the form of the senior mental health pharmacist. She also couldn’t make head or tail of it after we had spent another fifteen minutes discussing it.

In the end, we corrected the quantities to the current amounts, recorded what we had done, had all patients on tramadol M/R changed to tramadol and removed all tramadol M/R from the ward. I also instructed all staff that there needed to be two nurses involved in the administration of tramadol from here on in, as I was shocked to discover that this wasn’t already happening. The joyous task of completing an incident report awaits me on Monday.

It’s safe to say (well, one would hope) that this major an error won’t happen again on that ward. However, this has made me genuinely relieved that tramadol has become a controlled drug. Who knows how many errors have gone unnoticed due to stocking different strengths and no two-nurse checks or records in place? I envision that the experience of other pharmacists since the new legislation has been a pretty mixed bag too.

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