Have you made any dispensing errors while working? or anything else significant?

Started by ethyl
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ethyl

ethyl

Go suck on a Zoloft.
Verified Member
Pharmacist
15+ Year Member
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I know to err is human, so I was wondering how common are dispensing mistakes? I've encountered a second mistake from my local CVS within the past few months. Loritab in the bottle for Ambien and the Ambien in the bottle for the Loritab. 😉 And have you gotten any mistakes from your local pharmacy?
 
hmmm....no - not received any errors myself as a patient.

But.....I've made some which I'll never forget!!!! Most of my errors have never made it to the patient, but those few which did have been ones which will forever be etched into by being & ones that haunt me still!
 
ethyl said:
I know to err is human, so I was wondering how common are dispensing mistakes? I've encountered a second mistake from my local CVS within the past few months. Loritab in the bottle for Ambien and the Ambien in the bottle for the Loritab. 😉 And have you gotten any mistakes from your local pharmacy?
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The vet called in some pain killers or something for my dog and the dosage was astronomical for a 10 lb dog and could have killed her if we gave it to her.
 
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ethyl said:
I know to err is human, so I was wondering how common are dispensing mistakes? I've encountered a second mistake from my local CVS within the past few months. Loritab in the bottle for Ambien and the Ambien in the bottle for the Loritab. 😉 And have you gotten any mistakes from your local pharmacy?
Click to expand...


I have never worked in a retail pharmacy - so I dont know about their error checking procedure - but I can describe the hospital system.

- If it is a first time dose = the pharm tech will pull the drug (or compound)... Then the pharmacist will double check the drug to the order to the label. If a compounding occured - then the pharmacist will ask to see the empty containers/the steps that you completed to make the compound (like oral Vanco). If all is kosher - then the med can leave the pharmacy

- If the order is not a first dose = The order will be on the refill list. One pharm tech will pull the entire list - and another tech will check the list. After the double checking - the drugs are taken to the floor - where they must be placed into the PIXYS machine one drug at a time. The drug must be identified by name, along with the # to be restocked, and then finally placed inside the machine.

*** Even after all of this - I have still seen a couple of errors on the floor. Rarely will it be the incorrect drug. More often it is an incorrect dosage of a drug (especially drugs like Zocor). The drugs that use the same color for different strengths are the worse...

Wow - long winded, sorry 😉

~above~
 
I'm surprised that your hospital does tech check, have they considered having the pharmacist check the Pyxis items?
 
ethyl said:
I know to err is human, so I was wondering how common are dispensing mistakes? I've encountered a second mistake from my local CVS within the past few months. Loritab in the bottle for Ambien and the Ambien in the bottle for the Loritab. 😉 And have you gotten any mistakes from your local pharmacy?
Click to expand...

I was prescribed 6 oxycontin tablets for a migraine. When I got home and checked the bottle, it had actually been filled for 60!
 
ButlerPharm.D. said:
I'm surprised that your hospital does tech check, have they considered having the pharmacist check the Pyxis items?
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Our hospital is pretty small (150 beds not including ICU or ED), yet restocking the PIXYS still takes about 4 hours of the day. To have a Pharmacist check every restock would take about an hour - and they really can afford that much time simply double checking.

When a new drug is going to be loaded into a PIXYS, the pharmacist will verify it - there after, it will be double checked by techs before refills. SOP for us at Sand Lake Hospital in Orlando - how does it work @ your pharmacy???

~above~

To the Percocet overfill... That is every addicts dream, we have 3 or 4 "regulars" at the hospital that begin salivating any time a C2 drug is mentioned... haha
 
We get some pretty good typos when techs don't use their sig codes. One of the techs at work today typed a sig code: "instill 1 to 2 drops in affected earfs..." Wish I knew what an earf was...Good thing the pharmacist caught that when he verified the rx.
 
We have 2 clinical techs- theses are the techs that pull the meds from Pyxis for the floor nurses. The clinical techs are responsible for pulling Pyxis items for their floors. ALL PYXIS ITEMS are checked by a pharmacist in the central pharmacist prior to them being brought to floor for restocking. We also have our Pyxis tech- this tech is responsible for pulling the Pyxis reports and restocking ALL Pyxis machines throughout the hospital. The Pyxis tech works 8.5 hours and everything gets done.
 
ethyl said:
I know to err is human, so I was wondering how common are dispensing mistakes? I've encountered a second mistake from my local CVS within the past few months. Loritab in the bottle for Ambien and the Ambien in the bottle for the Loritab. 😉 And have you gotten any mistakes from your local pharmacy?
Click to expand...

You mispelled "Loritab" twice. The correct spelling is "Lortab."
 
TennisBoy78 said:
You mispelled "Loritab" twice. The correct spelling is "Lortab."
Click to expand...

Hey Grammar Boy....can u read over my personal statement??? j/k I already got in
 
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i work in a pharamcy and i find everything strange

i dropped a full bottle of pills on the dirty floor and the pharmacist told me to put it back in the bottle and take out whatever i needed from it for the prescription... and im like but... i thought its dirty..germs....and he just smilles at me so...go figure...
when u have to count alot of pills and someone is trying to talk to u ... it can get a lil messy and im sure there are mistakes by one two pills alot

i was doing a prescription and i was 1 or 2 pills short and the pharmacist told me its ok just give it to them they are not gona count it ..its ok .....soooooo.... 😀

i think its a good idea to stand there while they fill the prescription ...so we/they dont try to get smart..... :laugh:
 
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