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An Inside Look at Pharmacy Mistakes

Pharmacy mistakes happen too frequently. Pharmacists and technicians feel bad about them. Patients should check their prescriptions carefully.

We have frequently urged our readers to be vigilant whenever they pick up a prescription from the pharmacy. Check to make sure that the drug you were given is exactly what your doctor prescribed: same drug, same dose. Pharmacy mistakes are not rare. In this post, Dennis Miller, RPh, a retired pharmacist, gives us an inside view of pharmacy mistakes and how pharmacists and pharmacy technicians feel about them.

Pharmacy Technicians Can Be Devastated When They Make a Mistake:

Do you realize how important technicians are for the functioning of pharmacies and how critical it is that they be extremely careful and focused on their work? During my career as a pharmacist, I’ve seen technicians who span the entire spectrum. Some technicians are absolute superstars. Other technicians are a threat to public safety.

In the past, technicians were people who were very often hired with no previous pharmacy experience. They typically learned on the job. More recently there is a movement to have technicians certified in an effort to increase their competence and decrease the epidemic of pharmacy mistakes in drug stores across this country.

See for Yourself:

Regarding the epidemic of pharmacy mistakes, see a video report from KSDK in St. Louis (November 7, 2017) titled “Are business tactics at some pharmacies risking your health?”

See also a USA Today video titled “Man blinded after prescription mixup.” In this case, a patient alleged he was blinded in one eye as a result of a pharmacy erroneously dispensing an ear drop rather than the prescribed eye drop.

Who Is Watching the Store?

Pharmacists are ultimately responsible for every prescription that’s filled. But with the dangerously understaffed pharmacies that are too common in chain drug stores across America today, prescriptions often fall through the cracks without being adequately checked by pharmacists.

The big chains have sadly chosen a dangerous business model based on understaffing. Understaffing increases chain profitability by requiring all pharmacy staff to work at maximum output. But oppressive production metrics based on speed unquestionably increase pharmacy mistakes.

If a pharmacy is running an hour or two behind, very often the pharmacist simply has only a few seconds to check a prescription filled by a technician before it is dispensed. Sometimes the pharmacist is so exhausted from standing on his/her feet for 10 or 12 or 14 hours that he/she simply does not catch a technician’s error, even though the pharmacist actually eyeballs the prescription (however briefly). In too many chain drug stores, prescriptions are just a blur on a pharmacy assembly line.

How Pharmacy Technicians Feel About Pharmacy Mistakes:

The following discussion is condensed from a pharmacy technician’s recent post on a pharmacy discussion group (“Tales From The Pharmacy”).

Recently there was a drug error in our pharmacy where a patient was dispensed the wrong medication… from TalesFromThePharmacy

This discussion is from the perspective of a pharmacy technician, a perspective that the national media rarely focuses on. Pharmacy technicians play a critical role in today’s speed-is-all-that-matters chain drug stores. Technicians are also critically important in other pharmacy settings, including hospitals and independent pharmacies.

This pharmacy technician was devastated by a mistake she made, a mistake that the pharmacist on duty failed to catch. In this case, the pharmacy technician filled a prescription with an antidepressant rather than the prescribed immunosuppressant.

Pharmacy technician’s original post:

“Recently there was a drug error in our pharmacy where a patient was dispensed the wrong medication [an antidepressant instead of an immunosuppressant]. Somehow the pharmacist didn’t verify it close enough.

“The pharmacist is currently on leave and the realization [discovery of the error] arose the other day when the patient called asking if [he] got the wrong medication because [he wasn’t] feeling well.

“I feel completely terrible and I understand that I hold half of the responsibility, but I am feeling as though I have failed tremendously and all of the blame is on my shoulders because [the pharmacist] isn’t available to be informed of the error at this time. Every time I think about it I get so upset because my pharmacist failed to visually verify the medication and isn’t here to share the responsibility with me.

“I haven’t been able to talk about much of this with the new pharmacist in charge. On Monday I’m planning to have this talk. I’m looking for help with how I should approach the conversation with him because he hasn’t been at my store for long and was also pretty upset/baffled at how this happened. Note: he was also the person who answered the initial call from the patient when it first received attention.

“This has been keeping me up at night for several days because of the guilt I have for not paying close enough attention. I feel so terrible. When the patient came in to pick up the correct med, I grabbed the float pharmacist [a “floater” pharmacist “floats” between stores rather than being assigned to one store] there for the day and [he was] great about handling it with the patient and expressing how sorry we were.

“I did apologize to the patient personally and admitted that it was my name on the fill and unfortunately the error was not seen by the pharmacist at the time and therefore was not kicked back to me to resolve.

“Sadly he [the patient] just kind of nodded and looked away. I don’t blame him for it but it hurt so much to hear that he was feeling so physically affected from the error.

“I just don’t know. Please help.”

Another pharmacy technician responded:

“Honestly, you should feel bad to an extent, but it seems like you’re beating yourself up too much. Pharmacy mistakes happen. No one died.

“If your manager gives you a hard time, tell [him or her] that you already feel terrible and would prefer to approach this as a learning experience so you can make sure similar issues don’t happen again.

“For example, if you think the issue was putting something down mid-fill to help at the counter, don’t leave production [don’t interrupt your prescription filling] until the script in your hand is complete or you put it aside to be started from scratch. A quick “I’ll be right with you” should buy you the 30 seconds you need to finish what you’re doing.

“The culture at my hospital encourages safety and reporting issues because it helps to uncover systematic shortcomings where we can do better by changing a process or procedure. I’ve never felt penalized for a mistake and I’ve helped to change some policies because of my mistakes.

“When I worked retail, the culture was about figuring out who to blame instead of how it happened and how to prevent it from happening again.

“If you’re feeling extra guilty, offer to spearhead a patient safety project where you’ll come up with small process improvements to help with accuracy. Moving the ropinirole [Requip] further away from the risperidone [Risperdal] was helpful at my pharmacy as was putting pink stickers near meds that are easily confused like otic [ear]/ophthalmic [eye] dosage forms or levetiracetam [Keppra]/levofloxacin [Levaquin].

A pharmacist responded:

“Mistakes are unavoidable.

“All pharmacists make mistakes. All technicians make mistakes. I have had technicians catch my mistakes, and I have caught theirs. I have seen mistakes and questionable decisions of all kinds from all sorts of professionals. Nurses, PAs [physician assistants], pharmacists, and MDs. Everyone makes mistakes. Even when you think you have it nailed, you will see pharmacy mistakes being made by someone else down the line. I have carried mistakes with me for days and weeks at times, and I have also seen others who do the same over things I would consider to be relatively insignificant.

“Mistake are unavoidable. Learn from them and share your knowledge. That’s how you reduce the chance of them happening again.”

A technician responded:

“We’ve had 10 errors since June. Don’t beat yourself up over this.”

Another technician added:

“You are a human. You make mistakes. You did not do it intentionally, and you took responsibility for it. This speaks volumes about you.

“You could have just let the pharmacist handle it and not apologize personally. But you did. It’s also kind of strange that the patient just took it and didn’t notice that it looked different. Usually when a brand is changed there is a sticker. I wonder if [the patient was] feeling stupid themselves [for not immediately questioning the change in appearance of the pills].”

The original technician who made the error replied:

“Thank you. [The patient’s] wife is one of my favorite patients and when I heard it was him my heart sank for potentially losing their trust. He took three days’ worth before he thought to ask.

“I’m guessing what happened was in the middle of a rush. [The prescription] had been scanned through [entered into the computer] and I went to grab the front [assist a customer] and came back and put either the wrong patient’s sticker on the vial or grabbed the wrong stock bottle (that would have been on the counter from one of the last fills I was working on waiting to be reshelved). I don’t know. I want the surveillance to be pulled so I can see myself and the pharmacist making the mistake.”

Another technician commented:

“Don’t pull the footage. You’ll only beat yourself up more. Learn from it and move on. And don’t take so much of the responsibility. Yes, you filled it, but it is your pharmacist’s JOB to make sure it was filled correctly according to the script. I’ve misfilled before, and always felt bad about it, but my pharmacists always pointed out that they should have caught it and that ultimately it was on them.”

A nurse posted this:

“I’m a nurse but I lurk in this [discussion group] because of the dry humor that seems to be a pharmacy job requirement. I made a significant med error while working an inpatient drug & alcohol center. Honestly the only reason my patient had no adverse effects (except for sleeping through the night for the first time since admission) was because of his addiction-related tolerance. I could have easily killed him with the dose I gave.

“I’m still not clear on HOW I made the mistake I did because I don’t even remember interacting with that particular patient. It took me a few shifts to get my confidence back and feeling insecure at work was just as bad as the initial error. I was constantly second guessing everything I did and that started driving my coworkers nuts. I was getting flustered and making stupid mistakes. It wasn’t until one of my favorite coworkers snapped at me that I realized my guilt was self-serving and making things worse.

“You feel bad, you apologized, you thought about what did/might have contributed. Now let it go. Everyone makes mistakes and as long as you try to learn something from it you’ll be safer at your job than you were before it happened.”

About the Author:

The author, Dennis Miller, is a retired chain store pharmacist living in Delray Beach, Florida. He welcomes feedback at dmiller1952@aol.com. You can also post a comment below.

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies..
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