Fatal mistake

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Smileehogan

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I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.
 
Are we talking Dr ordered the wrong med and you didn't catch it, or tech filled the drug?
My advice would be to contact your liability insurance provider and see what they want you to do.
 
Tech entered wrong drug/ I verified it and pt took it for 2 months resulting in hospitalization. Liability office notified, but I just can’t seem to move past it. Are there anybody with experience that can tell me what to expect in terms of legal issues and how to eventually move on?
 
Do employers typically provide a malpractice insurance coverage or is that something that a pharmacist would typically buy on their own? Please share your experiences!
 
Do employers typically provide a malpractice insurance coverage or is that something that a pharmacist would typically buy on their own? Please share your experiences!

You buy it on your own from my experience. I’d recommend HPSO.


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Do employers typically provide a malpractice insurance coverage or is that something that a pharmacist would typically buy on their own? Please share your experiences!

Even if they did offer it, I'd buy my own.

Employers have successfully argued that employees terminate themselves the second they begin to commit a fireable offense
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.
We all make mistakes, but I am going to go out on limb here and guess that you work in retail? Particularly for a certain three letter change? My advice is you ask yourself why it happened and how likely it is going to happen in the future. If it happened because you work in a fast pace environment, perhaps you should switch to something like LTC. Where you work in a slower or more controlled environment. Perham you can switch careers and work as a advocate.
 
2 months? Was it dispensed twice as a 1 month supply?

Unfortunately there isn't any great advice for these situations. You need to separate legal and psychological issues resulting from this, as well as do the best you can to protect your license. I'm guessing you are under 30. You spend significant time in school. This is not pleasant but you can't throw in a towel. Do you have a better option as far as a career?
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.
It wouldn't hurt to see a therapist a couple of times.
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.

What was the drug?
 
Ok.
I have seen two major incidents (misfill) from my store and each pharmacists got sued.
One patient ended up in ER (got 10 times stronger strenth for steroid). And other patient had wrong sig (it was 1 qd but put got 2 bid).

To make long story short, both still are working.
Patients sued them and those pharmacists got some calls from lawyers, insurances and corporate. I dont know more detail but I do know that they are still working.
 
I'm not going to talk about the Eric Cropp case, since that was a travesty of justice. It is really situational. What gets to the pharmacist is the anxiety and self-doubt that never gets relieved even with legal closure. I used to work in the Office of Health Inspections, Inspector General for my agency (and still keep affiliate membership) and these misadventures happened which there are national committees that deal with peer review. I have seen everything from resumption of normal practice, resignation from a job, surrendering practice, and in three very unfortunate cases, suicide by both immediate and substance abuse means. Oddly enough, my agency does not fire personnel for honest mistakes (they will if a mistake was caused for controllable reasons like malice, lying during credentialing, or being under the influence and to say for some other issues, this agency has no problem firing whistleblowers). However, they have made forced reassignments and practice restrictions.

Absolutely follow what your liability insurance says, the lawyers for both Pharmacist Mutual and the APhA one are practiced. Also, I have probably committed the same mistake you have, but lucked out by either having it caught before harm or in a situation where harm was not the result. That sort of mistake can happen to anyone, and it is a combination of both a practice error and bad circumstantial luck.

It depends on your institution's culture for discipline for the involuntary part of your career fate. Just culture institutions won't get you fired, but will get you sidelined into retraining and administrative work until you resume (or not). Government covers it up, and if not, you just get an SF-50 reassignment to Quality and Performance to fill out paperwork on these incidents in ASISTS for the rest of your career (ironic, isn't it?).

What you need to do is basically acknowledge the misadventure for what it is, take accountability (but don't go out of your way to punish yourself, trust the system for that), and stay the course until this works through the system. If you feel like self-harm/suicide, you do need to get immediate professional help as that doesn't make the situation better for anyone especially yourself. In the cases that I took on, part of the script that comes with the matter is that I advise a practitioner not to act with a guilty conscience until after official action is complete and the practitioner had time to reflect on the process. The only exception was that if they thought that they were driven to distraction by brooding over the incident, in which case we reassigned them to a non-patient care position until psychologically fit to return.
 
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Do employers typically provide a malpractice insurance coverage or is that something that a pharmacist would typically buy on their own? Please share your experiences!

Yes, as others have said you should get your own. Big retail chains will tell you that they have malpractice insurance, but obviously that insurance is to protect the chain. Get your own to look out for your own interests.
 
I can relate to the OP somewhat because a similar situation happened to me, though it was not pharmacy related. I am not going to dwell on the details, but all that I will say is even though I was not at fault legally, I experienced a lot of mental anguish and self-blame. It definitely took a heavy toll on me. I never really get over it for that matter, but life moves on. I really wish for the best for the OP and hope that it will not be as serious as you thought it would be.
 
I'm going to guess it was hydroxyzine and hydralazine. Reminder to pharmacists to take it slow, its your license and the patients life on the line.

Wouldn't likely be fatal or cause hospitalization, though, right?

I once caught two separate errors involving mix-ups between Lamisil/Lamictal (look-alike/sound-alike) and another between Methotrexate/Meloxicam (similar tablet colors/imprints) that had me scared for awhile. Those could definitely be fatal.

I am curious too! But will respect the OP's privacy.
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.

You could also be facing serious jailtime. I would liquidate all your assets in preparation of a civil action being filed against you.
 
this exact case happened to a past co-worker of mine. Though the hospitalization was minor (less than 5K bill, not more than an ER evaluation & follow up) the patient settled with the insurance (rph had own coverage). Rph co-worker is somewhat more careful but what I gained from this was that any patient will sue you if they get hurt, even if the doctor writes scribbles and the name of the drug is clearly on the label. Even if you document counsel, they may have a case.
 
In my mis-spent life I have VERY narrowly avoided three (maybe four) of what would have been fatal screw-up's......in three different careers no less..in one I would have been among the deceased..sometimes out of the blue it actually pops into your head and stops you right in place...BUT time passes and you can't change it......Do the schools have ANY safety instruction?
 
Makes a case for mandatory consultation. Like real mandatory consultation and not ******* Walmart "they're getting a 90 day supply 6 days early so mandatory consult" It's not just checking a "counsel" box but actually seeing if the patient knows WTF they're getting
 
How much does rph pay when sued if they have malpractice insurance?
 
I wonder how effective HPSO is. There's really no way to know their success in negotiating / settling / litigating because we can't hear from the health professionals that have utilized their services. Can anyone shed some light on this? Given the scope and magnitude of the fallout should an error lead to someone's death, I really doubt a $1,000,000 or even $3,000,000 policy can be enough. Once the plaintiff is awarded policy limits, what's to stop them from going after you personally in another complaint or civil court?
 
...one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization

Tech entered wrong drug/ I verified it and pt took it for 2 months resulting in hospitalization

That doesn't add up. Patient took it for 2 days maybe?

And no one died so "fatal" isn't the right word.
 
I wonder how effective HPSO is. There's really no way to know their success in negotiating / settling / litigating because we can't hear from the health professionals that have utilized their services. Can anyone shed some light on this? Given the scope and magnitude of the fallout should an error lead to someone's death, I really doubt a $1,000,000 or even $3,000,000 policy can be enough. Once the plaintiff is awarded policy limits, what's to stop them from going after you personally in another complaint or civil court?

They send out emails with real examples of cases they have defended their clients against (supposedly). Now we can debate all day about selection bias and if the cases are even real, but they are interesting to read about.
 
I wonder how effective HPSO is. There's really no way to know their success in negotiating / settling / litigating because we can't hear from the health professionals that have utilized their services. Can anyone shed some light on this? Given the scope and magnitude of the fallout should an error lead to someone's death, I really doubt a $1,000,000 or even $3,000,000 policy can be enough. Once the plaintiff is awarded policy limits, what's to stop them from going after you personally in another complaint or civil court?

Yes, they are regulated as AIS Affinity (Aon) in NY and CA (I did not look super hard, but I think NY is their base regulatory state although for certain types of insurance, it's state specific). Their chief actuary was one of my examiners back in the day. They are actuarially sound as you can read in the filings in NY (NY and MA tend to be where the most detailed of the financial filings are). In terms of what is termed breakthrough liability claims (claims that a client must pay above the deductible due to maximum reaches), that does get reported to the insurance commission as underinsurance gets scrutiny for policy coverage regulation in the state (and penalties if you are consistently having breakthrough liability claims against a client). If you are willing to read the filings in each state, you could compile those statistics.

And actually, yes, that's enough from the perspective of some precedents set in the 70s for pharmacist misfills. Not to say that breakthroughs don't occur, but they also have to involve other issues as well.
 
You could also be facing serious jailtime. I would liquidate all your assets in preparation of a civil action being filed against you.

I think this is great advice. Create an LLC and put everything OP owns in its name OR double sleeve it, and create a second LLC that owns the first LLC.
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.

You must take care of yourself and seek counseling ASAP. Be good to yourself. Find a lawyer and only make statements through that attorney.
Get your own liability insurance. I feel this needs to be restated. I do not think most pharmacists; especially in retail, are aware that you MUST get your own.
 
I’ve been a pharmacist for 3 Years now. And one week ago I verified and dispensed the wrong medication that resulted in patient hospitalization. I am pretty devastated. All I can wish is for the patient to recover but I just don’t know how I can go on. It still feels like a dream/ nightmare. I Will probably be sued, get fired, which I feel is that I deserve but I really hope patient will be okay. Please give me some advice.

I meant to say I feel for you. I’m sorry this is happening to you. Unfortunately, this is a subject that’s never really talked about in pharmacy school. You would think that every time you make mistake in lab they’d “prosecute” you to the full extent of the law and have you reflect on the matter. That would be useful. Instead, we had to reflect on every nonsense under the sun.
 
We all make mistakes. I have made handful of mistakes in the past six years.. wrong strength.wrong direction. c 2 miscount. Some pharmacists are just unlucky that mistakes that they make end up harming patients. This one mistake won't define your ability as a pharmacist in any way. So don't beat yourself up over this. In my career, I have seen two serious mistakes that resulted in hospitalization. (Thank god I was not involved in them) ATHe first one is a technician selling the med to the wrong patient. Another one is that a pharmacist dispensed 100 mg instead of 10 mg. In both cases, pt had to go to the hospital. The first case.. nothing really happened. The company was able to resolve it with the patient. I am sure that the company had to give the family big compensation.. The tech continued to work. At this company, if you made two register mistakes, you were fired. It was her first mistake. The second case.. the patient sued the company but not the pharmacist. The pharmacist ended up getting fired, but this pharmacist was very notorious for making many mistakes.

One advice for you is that if you work for companies that have outdated computer systems, you will more likely make more mistakes. I would look for a company with better system like Walmart or Walgreens. My error rate dropped significantly when I switched from CVS to Walmart..

I hope that the patient recovers soon and be able to settle it with your company...
 
Yes, it's a numbers thing. Let's say 300 mistakes happen a day in the pharmacy world across the US. 200 are caught and corrected before the patient is given/takes the medication or get through completely undetected. 70 are corrected after the 1st dose and nothing happens to patient or pharmacist. Maybe 29 cases make it to the board after the patient complains and files for action against pharmacy/pharmacist.... and 1 unlucky pharmacist error results in hospitalization. Also, lawyers go after the big money and that will always be your employer/corporation.

I'm confused, did the OP make an error that resulted in patient death or just hospitalization?
 
Tech entered wrong drug/ I verified it and pt took it for 2 months resulting in hospitalization. Liability office notified, but I just can’t seem to move past it. Are there anybody with experience that can tell me what to expect in terms of legal issues and how to eventually move on?

So just to be clear here,

- Two months ago, tech entered wrong drug and you verified it,
- Patient took that medication for two months
- In the beginning of February, patient came back for a refill and you verified the refill.

When was the patient hospitalized?
 
I saw several significant errors related to physician order entry in hospital pharmacy. Not going to bull you, if you basically okayed the completely wrong drug and the patient died, that is very significant. But you don't want to Monday Morning quarterback yourself too much...you basically got set up with confirmation bias it sounds like since someone else initially entered it for you. The biggest errors I saw on the otherhand seemed to stem from pharmacists "changing" or "okaying" orders for convenience because what the doctor ordered made no sense. Assumptions are made to save time to deal with a heavy work load.

For example, an IV med was entered and the med is only available as a tablet. The pharmacist assumed and changed the route to PO to "help" the doctor out. The reason it was ordered IV is because it was the WRONG DRUG, not the WRONG ROUTE. The pharmacist who did it was one of the nicest fellows I met, but he was ostracized once that error occurred. Everyone around him began to think he was "unsafe" based on that gamble he took. Now if the patient didn't have such a bad outcome and it was just a wrong route issue, his judgement would have been "helpful" from behind the scenes.

If I was in your kind of environment, I'd make sure what I'm dispensing has an appropriate frequency for the drug and is an appropriate STARTING dose. I've seen outpatient prescriptions for Ciprofloxacin QID filled and it was pretty obvious the drug should have been Keflex. If the patient's tendons ruptured, the pharmacist would be the first to blame for sure.

I basically never take risks on heavy hitting med orders and if the medication is an hour late then those are the breaks because honestly no one has your back but yourself in the medicine business. I'll look at other orders while the crap order is being "worked on". I also make the person ordering it figure it out if the best option isn't obvious to me. I'm tired of people ordering garbage and then asking me to handle it.
 
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I saw several significant errors related to physician order entry in hospital pharmacy. Not going to bull you, if you basically okayed the completely wrong drug and the patient died, that is very significant. But you don't want to Monday Morning quarterback yourself too much...you basically got set up with confirmation bias it sounds like since someone else initially entered it for you. The biggest errors I saw on the otherhand seemed to stem from pharmacists "changing" or "okaying" orders for convenience because what the doctor ordered made no sense. Assumptions are made to save time to deal with a heavy work load.

For example, an IV med was entered and the med is only available as a tablet. The pharmacist assumed and changed the route to PO to "help" the doctor out. The reason it was ordered IV is because it was the WRONG DRUG, not the WRONG ROUTE. The pharmacist who did it was one of the nicest fellows I met, but he was ostracized once that error occurred. Everyone around him began to think he was "unsafe" based on that gamble he took. Now if the patient didn't have such a bad outcome and it was just a wrong route issue, his judgement would have been "helpful" from behind the scenes.

If I was in your kind of environment, I'd make sure what I'm dispensing has an appropriate frequency for the drug and is an appropriate STARTING dose. I've seen outpatient prescriptions for Ciprofloxacin QID filled and it was pretty obvious the drug should have been Keflex. If the patient's tendons ruptured, the pharmacist would be the first to blame for sure.

I basically never take risks on heavy hitting med orders and if the medication is an hour late then those are the breaks because honestly no one has your back but yourself in the medicine business. I'll look at other orders while the crap order is being "worked on". I also make the person ordering it figure it out if the best option isn't obvious to me. I'm tired of people ordering garbage and then asking me to handle it.
This post is the equivalent of one of us going to an MD forum and writing, "did u know u need to do stitches sometimes 4 a full thickness cut? Wow!"

I also didn't realize quinolone tendinopathy was a dose dependent toxicity.
 
This post is the equivalent of one of us going to an MD forum and writing, "did u know u need to do stitches sometimes 4 a full thickness cut? Wow!"

I also didn't realize quinolone tendinopathy was a dose related toxicity.

Giving out supratherapeutic doses of antibiotics is never a good thing; just from an antibiotic stewardship point of view. Personally, I would never dispense Ciprofloxacin 500 mg PO QID. If you need that much Cipro for the infection it's time to go to the hospital and get IV antibiotics that work way better. If the patient could have been treated with 250 mg BID for 3 days for that uncomplicated UTI, why go all big league with 500 mg QID because 1)waiting is inconvenient for the patient and/or 2) calling the doctor is hard. All I'm saying is examining a frequency is sometimes the tell tale sign that a completely wrong drug is picked. I know retail pharmacists get busy, but I'm desensitized to patients and/or nurses being angry with me, my license is more important than them.
 
Giving out supratherapeutic doses of antibiotics is never a good thing; just from an antibiotic stewardship point of view. Personally, I would never dispense Ciprofloxacin 500 mg PO QID. If you need that much Cipro for the infection it's time to go to the hospital and get IV antibiotics that work way better. If the patient could have been treated with 250 mg BID for 3 days for that uncomplicated UTI, why go all big league with 500 mg QID because 1)waiting is inconvenient for the patient and/or 2) calling the doctor is hard. All I'm saying is examining a frequency is sometimes the tell tale sign that a completely wrong drug is picked. I know retail pharmacists get busy, but I'm desensitized to patients and/or nurses being angry with me, my license is more important than them.
Yeah, what I'm trying to tell you is that is very obvious, minimum competency stuff.

We even understand that FQs are conc dep., so giving big doses like that outpatient is pointless.
 
Yeah, what I'm trying to tell you is that is very obvious, minimum competency stuff.

We even understand that FQs are conc dep., so giving big doses like that outpatient is pointless.

Alright man, maybe I was underestimating the knowledge base a bit. I still think pharmacists are the final and most important check before a medication error occurs. I did not mean to be condescending.
 
I saw several significant errors related to physician order entry in hospital pharmacy. Not going to bull you, if you basically okayed the completely wrong drug and the patient died, that is very significant. But you don't want to Monday Morning quarterback yourself too much...you basically got set up with confirmation bias it sounds like since someone else initially entered it for you. The biggest errors I saw on the otherhand seemed to stem from pharmacists "changing" or "okaying" orders for convenience because what the doctor ordered made no sense. Assumptions are made to save time to deal with a heavy work load.

For example, an IV med was entered and the med is only available as a tablet. The pharmacist assumed and changed the route to PO to "help" the doctor out. The reason it was ordered IV is because it was the WRONG DRUG, not the WRONG ROUTE. The pharmacist who did it was one of the nicest fellows I met, but he was ostracized once that error occurred. Everyone around him began to think he was "unsafe" based on that gamble he took. Now if the patient didn't have such a bad outcome and it was just a wrong route issue, his judgement would have been "helpful" from behind the scenes.

If I was in your kind of environment, I'd make sure what I'm dispensing has an appropriate frequency for the drug and is an appropriate STARTING dose. I've seen outpatient prescriptions for Ciprofloxacin QID filled and it was pretty obvious the drug should have been Keflex. If the patient's tendons ruptured, the pharmacist would be the first to blame for sure.

I basically never take risks on heavy hitting med orders and if the medication is an hour late then those are the breaks because honestly no one has your back but yourself in the medicine business. I'll look at other orders while the crap order is being "worked on". I also make the person ordering it figure it out if the best option isn't obvious to me. I'm tired of people ordering garbage and then asking me to handle it.

Wouldn't the physician take more heat for this than the pharmacist? The error originated with the physician that wrote the wrong drug.
 
Wouldn't the physician take more heat for this than the pharmacist? The error originated with the physician that wrote the wrong drug.

That’s my thinking as well.

I thought the newest guidelines clearly started FQs are not to be given for uncomplicated UTI; so why are we discussing that hypothetical situation (above)?


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Not sure I have a lot of great advice...just know that you are not alone. Pharmacists (and all healthcare providers) make mistakes sometimes. It sounds like (?) it wasn't fatal, so at least that's a blessing.

The most important thing you can do is learn from what happened so you don't make the same mistake again. If you let this kind of thing drag you down too much mentally, it may make it difficult for you to keep practicing pharmacy.
 
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