The actual script was to be supposed to be ONE daily for 10 days. The prescriber at the hospital screwed up and someone caught it over there.
Fortunately the medication wasn't dispensed yet. I went to the will call and sure enough, there it was filled and ready for pick up. It wasn't filled by me or Mickey. It was filled by a floater tech and floater pharmacist, probably during an incredibly busy time when things like this can slip by.
Even with our long chain of safeguards, every now and then a huge mistake slips right on through. When a pharmacy is understaffed and the staff is overworked, THAT is when bad things happen. Goofmart corporate doesn't give a damn. They expect us to just deal with it and be perfect.
I've made mistakes over the years, none of which has been anything that's been a big deal. With almost all mistakes it's been caught before it ever gets in the hands of the patient. The other situations didn't cause anything even remotely serious.
But I wonder, will someday a perfect storm of events take place that causes harm to a patient? Will I be the last link in the chain of protection for the patient that fails? Will I be the reason someone gets hurt?
And that keeps me up at night.
4 comments:
It keeps ALL of us imperfect human beings up at night! That "perfect storm" is the fear of all of us, thanks for verbalizing it, Crazy
Me Too.
http://www.cbc.ca/news/canada/toronto/go-public-sleep-medication-accidentally-switched-1.3811972
it can happen, it can be tragic. This popped up in my facebook news feed after I had read your blog post above.
No permanent harm was caused, but I was disappointed that my pharmacy didn't catch this one - the doctor wrote a script for 20mg Adderall for my 9 year old son. First time trying anything for ADD. Poor kid was still climbing the walls at 2AM that night, searching for a piece of paper. When I spoke to our family doctor, she was horrified. "That's a level for an adult male, not for a little boy!" A year and a half later, I finally agreed to try a 5mg dose for him and he says it's like the fog is gone and he can think clearly now. I will be forever sorry that I ever went to that first doctor, and let his crappy prescribing skills scare me away from getting my child the meds he needed. (p.s., the first thing the doc asked us at my son's initial eval was, "So, you want to get him on drugs for ADD?" and then proceded to talk to my son about cars for an hour.)
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