Advice needed- incorrect package sold to patient

[charo454]

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If anyone has any suggestions that would be great. I floated to a store about 2 months ago and recently found out that someone had sold an incorrect package to a patient (they did not verify name/address?!) and rang that transaction up while I was still signed into a register. Event was written up, and since this was the first time for me, I received a "verbal warning". I've gotten into contact with the manager at that store, and was basically told that there is nothing I can do about it since it was under my sign on. Yes, it is my fault that I didn't sign off and I accept that. But shouldn't the correct person be responsible for the repercussions?

There were several other cashiers that day and time. Our computer system can pinpoint as to the exact time a prescription was sold and there is digital video monitoring behind the counter. I've seen instances where they review the tapes looking for a specific transaction, but it seems like the manager at that store won't do that in this instance. I am 90% sure that it wasn't me, because I always make it a point to verify name/address and even circle it on the front label. I just want to know for sure and get some closure on this. If it was me, then I would absolutely be at fault and would deserve the verbal warning.

I am just really upset because even though this is a "verbal warning" the next step is being written up, then suspended, then let go. Another pharmacist told me I could take it up with a union, however I am not a member of the union. Should I just cave in and sign (and in effect concede that I was the one who did it) my verbal warning? Or is there anything else I can do?

 

[ForcedEntry]

They can't force you to sign anything, whether you did it or not.

Don't sign.

 

[IWantTheGenetic]

If anyone has any suggestions that would be great. I floated to a store about 2 months ago and recently found out that someone had sold an incorrect package to a patient (they did not verify name/address?!) and rang that transaction up while I was still signed into a register. Event was written up, and since this was the first time for me, I received a "verbal warning". I've gotten into contact with the manager at that store, and was basically told that there is nothing I can do about it since it was under my sign on. Yes, it is my fault that I didn't sign off and I accept that. But shouldn't the correct person be responsible for the repercussions?

There were several other cashiers that day and time. Our computer system can pinpoint as to the exact time a prescription was sold and there is digital video monitoring behind the counter. I've seen instances where they review the tapes looking for a specific transaction, but it seems like the manager at that store won't do that in this instance. I am 90% sure that it wasn't me, because I always make it a point to verify name/address and even circle it on the front label. I just want to know for sure and get some closure on this. If it was me, then I would absolutely be at fault and would deserve the verbal warning.

I am just really upset because even though this is a "verbal warning" the next step is being written up, then suspended, then let go. Another pharmacist told me I could take it up with a union, however I am not a member of the union. Should I just cave in and sign (and in effect concede that I was the one who did it) my verbal warning? Or is there anything else I can do?

I say fight it. Innocent until proven guilty, right? Get the time and watch the video recording. Sign nothing that admits guilt. I was in a situation where I was blamed for something I didn't do. As soon as I was done with working, I went to the front office and watched the day's recording. The video showed I was innocent.

 

[UBCmicrobi]

This is a really crappy situation 🙁

Our cash registers automatically sign you out after each transaction, thankfully (but not the Rx computers).

I wouldn't sign (admit guilt) until they looked at the security tapes.

Good luck

 

[MountainPharmD]

You know the policy. If it happened under your sign on it is your responsibility. You have no choice. Sign it and move on. I bet you won't forget to take yourself out of the register next time. Sometimes the best lessons learned are the ones you learn the hard way.

 

[charo454]

Mountain, I have been told that it is the policy, but how do I know that it's the policy and not just the manager's easy way out? A part of me wants to just get it over with, but the other part wants to know for sure who did it first. The manager told me that it "wasn't a big deal". But I'm getting a really formal "verbal warning" so to me it IS a big deal. Do you think that me actually going to the store and having the manager go through the tapes is overreacting? I don't want to seem like a nut that wants to place the blame on someone else. I just want to know for sure if it was me that slipped up because I take extra care not to.

 

[MountainPharmD]

Mountain, I have been told that it is the policy, but how do I know that it's the policy and not just the manager's easy way out? A part of me wants to just get it over with, but the other part wants to know for sure who did it first. The manager told me that it "wasn't a big deal". But I'm getting a really formal "verbal warning" so to me it IS a big deal. Do you think that me actually going to the store and having the manager go through the tapes is overreacting? I don't want to seem like a nut that wants to place the blame on someone else. I just want to know for sure if it was me that slipped up because I take extra care not to.

It is the policy at every chain (3) that I have worked at. I would want to see the evidence they have. Make sure they did not make a mistake and the error did happen on your sign in.

If you fight it and they find out someone else made the error on your sign in you trade one write up for another. They could write you up for failing to sign out of the register.

Get ovet it and learn from it. You have to pick your battles with management. This one is not worth it.

 

[MountainPharmD]

Opps!! DP...

 

[will7678]

As another option you could sign it after making a note on the write up that you believe that you were not the one to make the transaction. You could also note that you have asked to view the tapes and that has not been allowed at this time. However....any manager from here forward that sees that write up is going to think you are a problem employee and good luck getting any promotion. Your best bet really is to just sign it. Maybe you could make a deal with your boss that if you go another 6 months without a mistake they will remove it from your file as if it never really happened. Win-win situation for everyone.

 

[Old Timer]

Just how do you sign a verbal warning?

 

[diplomat]

I wouldnt sign it until i viewed the tapes. Like the other poster stated, if they force you to sign it write a note next to it stating your position. Make sure you write it on the front of the verbal warning. Do NOT allow them to say, "here is another piece of paper where you can write your side of the story." They will just throw out your statement. Make sure you statement is with the signature.

 

[Pharmavixen]

You know the policy. If it happened under your sign on it is your responsibility. You have no choice. Sign it and move on. I bet you won't forget to take yourself out of the register next time. Sometimes the best lessons learned are the ones you learn the hard way.

You can't be serious! Not signing out of a register is a minor oversight at worst. Selling the wrong package to a pt is potentially serious. So because you make a minor mistake, you're supposed to take the blame for someone else's much MUCH more serious mistake?? I don't think so - makes it easier for management, but a pharmacist who habitually lets him/herself be a doormat like this can only hurt their career.

Don't sign anything that says you made a mistake you didn't make.

 

[MountainPharmD]

You can't be serious! Not signing out of a register is a minor oversight at worst. Selling the wrong package to a pt is potentially serious. So because you make a minor mistake, you're supposed to take the blame for someone else's much MUCH more serious mistake?? I don't think so - makes it easier for management, but a pharmacist who habitually lets him/herself be a doormat like this can only hurt their career.

Don't sign anything that says you made a mistake you didn't make.

This OP has stated that he is unsure if he made the mistake. His code was in the register when the error happened.

Leaving your code in the register is not a minor oversight. What if someone stole $100.00 while you were signed in? Log off everytime you leave the register and you won't have to worry about being written up for what someone else did.

 

[jyw003]

No matter who did it, because you we're signed on, it is under your name and you have to take the fall. Sign it and question later. Even if you discovered who did it, in the end, all that hard work to prove your innocence could have been used for something else. Take the fall my friend...in time, if it happens again and again, the true identity of the perpetrator will be revealed.

 

[Pharmavixen]

Leaving your code in the register is not a minor oversight. What if someone stole $100.00 while you were signed in? Log off everytime you leave the register and you won't have to worry about being written up for what someone else did.

Someone did steal $200 from my till, and I was fired for it. Turned out it was the boss, who had a gambling problem. I was quietly rehired at another branch of the same chain, no penalties and a higher salary.

But by your logic, I should have meekly accepted the accusation of being a thief, instead of doing what I did, which was phone various vice-presidents of the company, and threaten to sue.

 

[BMBiology]

If you are sure you did not make the mistake, then ask for proof. No computer system is 100% accurate. This can be easily verified. It is a reasonable request.

 

[MountainPharmD]

Someone did steal $200 from my till, and I was fired for it. Turned out it was the boss, who had a gambling problem. I was quietly rehired at another branch of the same chain, no penalties and a higher salary.

But by your logic, I should have meekly accepted the accusation of being a thief, instead of doing what I did, which was phone various vice-presidents of the company, and threaten to sue.

Okay...I am going to go back and review for you. IF YOU ARE SIGNED IN TO THE REGISTER OR THE COMPUTER WHAT HAPPENS WHILE YOU ARE SIGNED IN IS YOUR RESPONSIBILITY. I hope I made that clear for you. I can underline it and put it in bold if that helps.

The bottomline is to sign out of the god damn register when you are done and this kind of thing will not happen to you. Log off everytime you leave the register and you won't have to worry about being written up for what someone else did.

 

[beaver333]

Take the responsibility for not logging out of the register after the transaction, but I think you should find out who actually made the mistake by reviewing the tape. There is nothing wrong in that. It will help you to move on...

 

[Pharmavixen]

Okay...I am going to go back and review for you. IF YOU ARE SIGNED IN TO THE REGISTER OR THE COMPUTER WHAT HAPPENS WHILE YOU ARE SIGNED IN IS YOUR RESPONSIBILITY. I hope I made that clear for you. I can underline it and put it in bold if that helps.

The bottomline is to sign out of the god damn register when you are done and this kind of thing will not happen to you. Log off everytime you leave the register and you won't have to worry about being written up for what someone else did.

This is totally true, and when I train people, these are the sorts of things I say.

However, just to clarify, what I'm on about is my perspective as a health care professional. A "real" mistake is one that potentially impacts on the health of a person, like filling a script with the wrong drug, or, say, giving out a package to the wrong person. All other mistakes are bureaucratic ones; the sort of things that the boss and his grade-12 education (if he's lucky) will wave in your face as proof of your incompetence; things you overlooked because you were too busy saving lives.

Like a nurse friend said, "There's no such thing as a paperwork emergency. An emergency is when someone is dying."

 

[BMBiology]

Log off everytime you leave the register and you won't have to worry about being written up for what someone else did.

That is true but shouldn't the person who used your register be held to the same standards? Shouldn't that person also be held accountable?

 

[bananaface]

I'd rather be written up for not signing out than for giving out the wrong medication.

 

[lamzee]

I live in Ireland so the law may be different, but are you not automatically responsible for everything whilst you are on duty, since you are professionally liable? In other words, if one of your shop staff gave the wrong parcel out at the till, is it not automatically your responsibility anyway, even if another person did it, since they are unqualified and can't hold legal responsibility anyway?

 

[MountainPharmD]

A "real" mistake is one that potentially impacts on the health of a person, like filling a script with the wrong drug, or, say, giving out a package to the wrong person. All other mistakes are bureaucratic ones;."

I completely disagree with you. A mistake is a mistake regardless of the perceived severity. Remembering to log out of the register or any of the other "small" or "bureaucratic" errors you mention requires the same attention to detail it takes to select the correct drug or the correct patient. I have had lazy, sloppy pharmacists use that line of reasoning with me and I do not buy it. You may think missing the refills or days supply or the date on a prescription is not serious. I see them as a signs of a potential bigger problem waiting to happen. If you are not paying close attention to detail and are missing the “small” stuff it is only a matter of time before you miss something serious.

In my pharmacy there are no small errors. Small errors lead to big errors.

Like a nurse friend said, "There's no such thing as a paperwork emergency. An emergency is when someone is dying."

Again, a sloopy lazy nurse would use this kind of excuse. My wife is a nurse. I should sick her you about this one. As my wife has told me. If you did not chart it, it did not happen. A nurse may be running around saving lives but now one knows it unless they chart it.

 

[Pharmavixen]

I live in Ireland so the law may be different, but are you not automatically responsible for everything whilst you are on duty, since you are professionally liable? In other words, if one of your shop staff gave the wrong parcel out at the till, is it not automatically your responsibility anyway, even if another person did it, since they are unqualified and can't hold legal responsibility anyway?

Here in Canada, the pharmacist is liable for every script that you sign for. But if a tech gave out medication to the wrong person when I went to the bathroom, say, I would not be liable, as long as I filled the prescription correctly.

A mistake is a mistake regardless of the perceived severity.

Strictly speaking that is true. However, we are all human, and make mistakes. When I worked in retail, and it got very busy, I tended to prioritize, focusing on the scripts, making sure things got billed correctly, etc.

Some of the things you're saying remind me of why I don't work in retail any more. Like, it's the middle of the supper rush, I've got a line-up, and the manager is yelling at me because there's $5000 in cash in the till, and I should have called him to take a skim, and if we got robbed, it would be my fault that the (non-existent) thieves got such a big haul.

 

[will7678]

I completely disagree with you. A mistake is a mistake regardless of the perceived severity. Remembering to log out of the register or any of the other "small" or "bureaucratic" errors you mention requires the same attention to detail it takes to select the correct drug or the correct patient. I have had lazy, sloppy pharmacists use that line of reasoning with me and I do not buy it. You may think missing the refills or days supply or the date on a prescription is not serious. I see them as a signs of a potential bigger problem waiting to happen. If you are not paying close attention to detail and are missing the “small” stuff it is only a matter of time before you miss something serious.

In my pharmacy there are no small errors. Small errors lead to big errors.




Again, a sloopy lazy nurse would use this kind of excuse. My wife is a nurse. I should sick her you about this one. As my wife has told me. If you did not chart it, it did not happen. A nurse may be running around saving lives but now one knows it unless they chart it.

Darn you beat me to it. I was just about to throw out this exact same quote. I am an ICU nurse and at every single code guess what one nurse is assigned to do? Document everything. So in the middle of someone dying we have a paperwork emergency. Which is extremely important since if you ask a few different people what meds were given during a code with all of the adrenaline pumping you may very well get many different answers.
In health care small mistakes may lead to very big consequences and even these "small" mistakes should be addressed. However no one is perfect and you are not expected to be. When you are caught in a mistake, or even involved in a mistake with another unknown person, you need to be an adult and use that as a learning opportunity. Pointing fingers and dragging out what should be a relatively quick coaching opportunity will not help you professionally. My job before health care was management and I can guarantee that anyone that refused to sign a warning would never see a promotion in the forseeable future. Don't think that it is fair...well its not but until you are the one running things you don't get a whole lot of say unless your boss starts doing something illegal.

 

[OldPharmer]

You know the policy. If it happened under your sign on it is your responsibility. You have no choice. Sign it and move on. I bet you won't forget to take yourself out of the register next time. Sometimes the best lessons learned are the ones you learn the hard way.

True.Get into the habit of signing off the register when you walk away ... it's a matter of hitting 2 keys.

This is obviously a Walgreens situation (based on the terminology used) and yes, their paperwork on IPP has gotten more stringent. Just sign it and move on. The form that is signed is kept on file and is SUPPOSED to be used to document the 2nd, 3rd, 4th incidents that may occur. When you move from one to store to another, this paperwork is often lost in the shuffle and therefore a new form will be used for the next infraction. Make sure the documentation is on the form (front or back) that states the steps you took to clear yourself (asking the MGR to review video, etc. and keep a copy for yourself).

But, like I tell my techs when I have to write them up for IPP ... learn a lesson from it and do what you have to do to avoid it in the future - sign off the register, verification terminal, scales, etc. when you walk away from them!

 

[lorain]

i made a mistake today: gave the pt freestyle normal strips and not the freedom lite....oops my bad...the manager said to file a report, but i didnt since i dont think its a big deal

 

[OldPharmer]

i made a mistake today: gave the pt freestyle normal strips and not the freedom lite....oops my bad...the manager said to file a report, but i didnt since i dont think its a big deal

If you work for WAG and it left the store, you have to. It's the company policy. If another mistake were to be made for this same customer and they complain that it's happened before (your error today) and it's not documented somewhere, there could be a problem.

I document the hell out of everything no matter whether it's my error or not. Or if there is a complaint by a staff member about another staff member, I document the whole problem after discussing it with them. That way, if there's a future problem, I have the documentation on hand to protect myself and them. I need to be able to show the company that action was taken and what the action was in case it comes up again. That's why we have a disiciplinary policy of verbal warnings->written warnings->suspension->termination. Fairness is key.

 

[lorain]

If you work for WAG and it left the store, you have to. It's the company policy. If another mistake were to be made for this same customer and they complain that it's happened before (your error today) and it's not documented somewhere, there could be a problem.

I document the hell out of everything no matter whether it's my error or not. Or if there is a complaint by a staff member about another staff member, I document the whole problem after discussing it with them. That way, if there's a future problem, I have the documentation on hand to protect myself and them. I need to be able to show the company that action was taken and what the action was in case it comes up again. That's why we have a disiciplinary policy of verbal warnings->written warnings->suspension->termination. Fairness is key.

you are right, but im too busy doing 600 + shots to fill the report out...hell, the other week some1s ativan was sold to another person, so the rph on duty had to redo the rx and give the ativan to the right person, and no one knows to whom the original ativan was sold too....i would think this would be a bigger issue, but no report was filed at last check lol...

 

[Sparda29]

If you work for WAG and it left the store, you have to. It's the company policy. If another mistake were to be made for this same customer and they complain that it's happened before (your error today) and it's not documented somewhere, there could be a problem.

I document the hell out of everything no matter whether it's my error or not. Or if there is a complaint by a staff member about another staff member, I document the whole problem after discussing it with them. That way, if there's a future problem, I have the documentation on hand to protect myself and them. I need to be able to show the company that action was taken and what the action was in case it comes up again. That's why we have a disiciplinary policy of verbal warnings->written warnings->suspension->termination. Fairness is key.

That word...documentation, getting tired of hearing that word everywhere when it comes to pharmacy.

 

[Vitamin K]

you are right, but im too busy doing 600 + shots to fill the report out...hell, the other week some1s ativan was sold to another person, so the rph on duty had to redo the rx and give the ativan to the right person, and no one knows to whom the original ativan was sold too....i would think this would be a bigger issue, but no report was filed at last check lol...

Not sure what you're "lol"ing about. I don't think it's funny that someone got the wrong medication and nobody cared to look into it. There should have been a report filed, for this and for the strips. Just because it's "not a big deal" for this one incident doesn't mean that it shouldn't be documented. Very irresponsible and unprofessional.

 

[MustLoveDrugs]

That word...documentation, getting tired of hearing that word everywhere when it comes to pharmacy.

I suggest you get familiar with "that word" before you graduate from pharmacy school in 2012. I still remember the first time a professor said to me, "Document. Document. Document." And I still remember thinking they were being a bit dramatic about the whole thing. But when it's your patient's life on the line and your license in jeopardy, you'll document. And you'll be glad you did.