File report or leave it for your partner

[ancienbon]

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Say that you are working on Friday and you find a error that occurred during your partner's shift. Label on amber vial for prednisolone has wrong directions while the direction on computer has correct direction. Infant is 7 month old. Dose should have been 1/2 teaspoon but instead is 2.5 teaspoons. Mom realized that and took infant to the er. Er said everything is ok with the infant,
You called the doctor but the office had already closed.
You left a detail note for your partner to investigate what happened and advised him to file an incident report as he was working that day.

Did I do anything wrong or should i have filed the report myself? I wont be working until wed next week.

 

[Aznfarmerboi]

Say that you are working on Friday and you find a error that occurred during your partner's shift. Label on amber vial for prednisolone has wrong directions while the direction on computer has correct direction. Infant is 7 month old. Dose should have been 1/2 teaspoon but instead is 2.5 teaspoons. Mom realized that and took infant to the er. Er said everything is ok with the infant,
You called the doctor but the office had already closed.
You left a detail note for your partner to investigate what happened and advised him to file an incident report as he was working that day.

Did I do anything wrong or should i have filed the report myself? I wont be working until wed next week.

You should always file an initial notification to protect yourself and your partner. The reason why is you can be terminated if you do not because you are putting Cvs at a liability.

On the other hand, there is no repercussions to filing an incident report. We all make mistakes. The incident reports are used to help the company collect data and use it as a training tool and risk management.

That way CVS can know where mistakes are happening before and after programs (for example there are more mistakes originating from data entry after rollout of "x", or certain drugs have more errors so they can put a hard stop or red flag warning on it.

In addition, if a pharmacist does make a lot of mistakes (like A LOT), they are put into a program where it narrows the type of mistakes the pharmacist makes and have that RPh double check it. So if your partner consistently makes a mistake on "sig/direction", they will be put on probation with an action plan ie triple check sig/direction on each script 2-3 times. The idea is to help the pharmacist change their verification process so they can reduce their error rates.

I have only heard of one rph getting fired from this.

In the real world though, I had partners who are afraid of this, and partners who are over zealous with it. For example, they report script wrong if day supplies is wrong, sig is not as exactly as prescriber written, or something that could have been resolved with MD call ( Fioricet,s Tylenol 300 vs 325) etc.

 

[owlegrad]

I report my own errors and leave it up to my partner to report to his. I would have done what you did and just leave him a note. I suppose I would report a floaters errors because they wouldn't likely have a chance to report their own.

 

[VP_Pharm2004]

On the other hand, there is no repercussions to filing an incident report. We all make mistakes. The incident reports are used to help the company collect data and use it as a training tool and risk management.

That way CVS can know where mistakes are happening before and after programs (for example there are more mistakes originating from data entry after rollout of "x", or certain drugs have more errors so they can put a hard stop or red flag warning on it.

That's a bunch of bull. We all know the real reason why mistakes happen... because pharmacists are pushed to complete orders in the allotted wait times. Do you even see CVS analyze mistakes and say... well, maybe the pharmacy is SHORT STAFFED and the pharmacists are stressed the hell out?!

It's easier to payoff people in lawsuits than actually be proactive to fix the REAL issue by offering more help, because like you said "mistakes happen". It's no big deal, right?

 

[doublehh03]

That's a bunch of bull. We all know the real reason why mistakes happen... because pharmacists are pushed to complete orders in the allotted wait times. Do you even see CVS analyze mistakes and say... well, maybe the pharmacy is SHORT STAFFED and the pharmacists are stressed the hell out?!

It's easier to payoff people in lawsuits than actually be proactive to fix the REAL issue by offering more help, because like you said "mistakes happen". It's no big deal, right?

They do, and they should. There was a mix up of lamotrigine and losartan generic b/c the bottle looks exactly the same pretty much in my old district. A 24 hour store mixed it when pouring into the script-pro. Now whenever you fill and scan the bottle, it will flag it to make sure you have the right bottle. So filing incident reports is a MUST.

CVS has a lot of cons, but they're not stupid to be ignoring incident reports, especially if there is a trend.

But ALWAYS report OP. That's an IR. You can do the initial in the computer, and leave the detail process for your partner after he follows up and checks everything out.

 

[ancienbon]

But ALWAYS report OP. That's an IR. You can do the initial in the computer, and leave the detail process for your partner after he follows up and checks everything out.

I guess i will report it next time i come to work if he does not report it. I left a detailed note and even mentioned filing a report will protect us should the patient complains

 

[PharmNerdMatt]

CVS actually has a policy on this. When I was last there, the person who discovered the error was supposed to start the initial report that shift, with the final report being done within 1 business day.

 

[ancienbon]

CVS actually has a policy on this. When I was last there, the person who discovered the error was supposed to start the initial report that shift, with the final report being done within 1 business day.[/QUOTE
So you think it will be too late to file a report when i go back to work. I always report my mistake though

 

[ancienbon]

So you think it will be too late to file a report next week.

 

[PharmNerdMatt]

I think it is your responsibility to make sure the report is done and done correctly. You can leave it, you just have to know that it is late if you don't do the preliminary the same shift. And, now that I think about it, the final might have 72 hours. It was certainly something that was in all that training you did at onboarding.

 

[ancienbon]

Thank you all for your feedback. The full report should be done in 72 hrs. so I still have time. though I should have initiated the report upon discovery.
Thanks again for your feedback.

 

[ancienbon]

You should always file an initial notification to protect yourself and your partner. The reason why is you can be terminated if you do not because you are putting Cvs at a liability.

On the other hand, there is no repercussions to filing an incident report. We all make mistakes. The incident reports are used to help the company collect data and use it as a training tool and risk management.

That way CVS can know where mistakes are happening before and after programs (for example there are more mistakes originating from data entry after rollout of "x", or certain drugs have more errors so they can put a hard stop or red flag warning on it.

In addition, if a pharmacist does make a lot of mistakes (like A LOT), they are put into a program where it narrows the type of mistakes the pharmacist makes and have that RPh double check it. So if your partner consistently makes a mistake on "sig/direction", they will be put on probation with an action plan ie triple check sig/direction on each script 2-3 times. The idea is to help the pharmacist change their verification process so they can reduce their error rates.

I have only heard of one rph getting fired from this.

In the real world though, I had partners who are afraid of this, and partners who are over zealous with it. For example, they report script wrong if day supplies is wrong, sig is not as exactly as prescriber written, or something that could have been resolved with MD call ( Fioricet,s Tylenol 300 vs 325) etc.

What is the Qa program about?
An Emerging leader told me that the QA program is for rph that make lot of mistakes . If they make another mistake , they get fired...is it true?

 

[zelman]

What is the Qa program about?
An Emerging leader told me that the QA program is for rph that make lot of mistakes . If they make another mistake , they get fired...is it true?

Double secret probation!

 

[Dred Pirate]

When I worked for OSCO - we had 72 hours from the time and error was found to when we had to report it - if it was not done in time and corporate found out about it - it was a $4,000 find to the store. I had not issues if someone would have reported me for an error such as this and I would have no issues reporting one of my co-workers if the error lead to an ER visit, - report it, if you don't - you are risking your job. I reported myself for making a cosopt vs azopt error because I could not read the script.

 

[WVUPharm2007]

Just report it ASAP. As long as you weren't being obnoxiously incompetent, you'll be fine. We all make errors. I've had to submit 3 of them on myself...nothing came of them. Even the best pharmacist on the planet will make at least a couple of errors a year and the bosses know this.

 

[Aznfarmerboi]

What is the Qa program about?
An Emerging leader told me that the QA program is for rph that make lot of mistakes . If they make another mistake , they get fired...is it true?

No. I think the company has only fired one pharmacist for mistakes from QA program and that was because he was making excessive mistakes even with a plan in place.

The QA program is for any pharmacists who makes a lot of mistakes or a mistake that resulted or almost resulted in serious injury to a patient. The idea of the QA program is not to fire people in it. If anything, they have made it clear that anything QA related should not be "punitive". If you ever ask around, you would know that nobody ever gets fired from it, or nobody ever gets in trouble for making mistakes. People make mistakes all the time....

Basically the QA program narrows down where a pharmacist makes mistake. For example, maybe a pharmacist is not checking sig clearly or the drugs entire name so they are making a lot of mistakes on sigs and ERs/ ODTS drugs etc. The program narrows it to that that based on previous incident reports and puts the pharmacist on probation for those types of mistakes. The pharmacist is given many chances not to repeat the error (I think 3 chances) over a period of time (1 to 3 months).

It can also narrow it into other variables like maybe a pharmacist is more prone to making mistakes at night time because they are tired....