For pharmacists, how much tolerance is there for mistakes?

[jjoeirv]

For pharmacists, how much tolerance is there for mistakes made in terms of the wrong medication dispensed or the wrong dilution made? If a serious mistake occurs where a patient is harmed or dies, would that be the end of the pharmacist's career or is the pharmacist able to make maybe 5 or 10 mistakes over a 1 year period before his or her career is over?

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[lord999]

Depends on the error. Forgetting to type "PR" for Anusol can be embarrasing, but mistakes with chemotherapeutics and radios in the hospital, and Coumadin, narcotics, and young ped doses can easily be a career ending mistake. Even though your profs say that we are on judgmental law, we are also responsible for 100% technical accuracy.

However, we are human. Do the math. If every pharmacist was 99.999% accurate (but realistically it is about 85-90%), dispenses 100 Rxs per day for 250 workdays, he or she would make 2.5 errors that leave the pharmacy per annum. It's quite a frightening number.

Read the posts about risk management for further detail, but being a nice guy smoothes over most major disasters.

BTW, slow pharmacies (beneath 150/day) make more mistakes (and major mistakes) than busy pharmacies contrary to popular belief.

 

[Rfour]

I find that hard to believe. Where is your evidence? ^^^

 

[lord999]

I'm sorry, I was wrong. We make 4 errors a day...


J Am Pharm Assoc (Wash). 2003 Mar-Apr;43(2):191-200.
National observational study of prescription dispensing accuracy and safety in 50 pharmacies.

Flynn EA, Barker KN, Carnahan BJ.

Center for Pharmacy Operations and Designs, Harrison School of Pharmacy, Auburn University, Ala. 36849-5506, USA. [email protected]

OBJECTIVES: To measure dispensing accuracy rates in 50 pharmacies located in 6 cities across the United States and describe the nature and frequency of the errors detected. DESIGN: Cross-sectional descriptive study. SETTINGS: Chain, independent, and health-system pharmacies (located in hospitals or managed care organizations). PARTICIPANTS: Pharmacy staff at randomly selected pharmacies in each city who accepted an invitation to participate. INTERVENTION: Observation by a pharmacist in each pharmacy for 1 day, with a goal of inspecting 100 prescriptions for dispensing errors (defined as any deviation from the prescriber's order). MAIN OUTCOME MEASURE: Dispensing errors on new and refill prescriptions. RESULTS: Data were collected between July 2000 and April 2001. The overall dispensing accuracy rate was 98.3% (77 errors among 4,481 prescriptions; range, 87.2%-100.0%; 95.0% confidence interval, +/- 0.4%). Accuracy rates did not differ significantly by pharmacy type or city. Of the 77 identified errors, 5 (6.5%) were judged to be clinically important. CONCLUSION: Dispensing errors are a problem on a national level, at a rate of about 4 errors per day in a pharmacy filling 250 prescriptions daily. An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.

 

[baggywrinkle]

Originally posted by lord999
Depends on the error.

It also depends on how injured the family feels and how aware they are of their options. It doesn't matter what the error is, if the consumer is angry enough to pick up the phone and complain to the BOP you will find yourself in a hearing. Never forget that the function of the BOP is to protect the public. They are not your buddy.

This action is rare. But note, if an error is extreme enough to make the papers such as the Walgreens methadone/ritalin error in New Mexico, chances are you will be hearing from the board in addition to your woes in civil court.

Help me out here, I am straining my memory. As I recall the definition of pharmaceutical accuracy is plus or minus 5%. Does this mean we can kill 5% of our patients and still be within tolerance?

There is not a pharmacist alive that has not run up the stairs in a cold sweat or spent a restless night staring at the ceiling. You show me a pharmacist who has not made an error and I'll either show you a liar or someone who has not been in practice very long.

If there is any single commandment to tattoo on your forehead it would be this. Thou shalt not harm a child. It doesn't matter what kind of sweatshop you are working in, know a pedi prescription when it is staring you in the face and take the time to be sure it isn't FUBAR. Stand your ground. Piss off a dozen customers and as many docs - shut the damned place down if you must but do not ever ever hurt a kid.


Just remember that there are errors and there are errors. Pray that you fall in the first category and not the second . For every error in the first category, thank your lucky stars and LEARN from it.

 

[loo]

Well put, baggywrinkle...soo, soo true!

Take your time and do it right. If the customer complains, tell them you CARE enough NOT to kill them. This *usually* shuts them up.

If you make a mistake, own up to it and reassure the patient. DO NOT try to cover it up or lie...you are asking to be sued. Most people are reasonable, but there are exceptions...

loo