“Label Swap” attack

[Xarelto-10]

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Okay been wondering in Hospitsl or retail setting if One wants to take a label you signed on and relabel the wrong drug/product etc....there is no way to proof otherwise is there?

I was wondering if there is any type of solution for that ? How do you protect your patieents, and your license ?

Eg: you signed on Asa 325 mg po tabs
Someone “intentionally removed that label with your signature on it and put Coreg tablets and screamed “Med error”

How can one prevent that ?

 

[Saiyo]

To resolve the issue you bring up, I would order some tamper resistant bags that must be individually sealed. After you check the med, seal the bag and sign the outside.

Really though, if someone really wants to screw you amd harm a patient they could quite easily.

 

[Xarelto-10]

That’s one approach I guess. Although I doubt how practical it would be with added cost to buy each tamper proof bag.

 

[Rouelle]

I generally just assume that the people I work with are not murderous sociopaths. It may be a poor assumption, but it has got me by so far.

 

[Rouelle]

In full seriousness, is this something you’re dreaming up as a general “what if,” or do you suspect this is happening? If the latter, report your suspicions immediately.

 

[ranger99rx]

Okay been wondering in Hospitsl or retail setting if One wants to take a label you signed on and relabel the wrong drug/product etc....there is no way to proof otherwise is there?

I was wondering if there is any type of solution for that ? How do you protect your patieents, and your license ?

Eg: you signed on Asa 325 mg po tabs
Someone “intentionally removed that label with your signature on it and put Coreg tablets and screamed “Med error”

How can one prevent that ?

None. Most of the time patient combine bottles without looking (same color pill) then stop by your pharmacy and ask why are 2 different kind of pills in my bottle. One time, an angry customer came in Walmart and showed us a few pills that looked different from the recent one we had refilled for him. After ID them, they were acetaminophen from target!

 

[Xarelto-10]

I would like to believe in our benevolence tendencies. At the same time I have seen situations to where people were doing reckless sabotage that could potentially end up hurting patient.
It happens. Some people are that much determined. It is sad but true. That’s why I treat everything I receive for verification potentially erroneous.

I generally just assume that the people I work with are not murderous sociopaths. It may be a poor assumption, but it has got me by so far.

 

[Xarelto-10]

I had a situation where an incident took place early December. Discovered on it around 12/8. But not brought to my attention until almost a month latter.

The incident also didn’t make sense to me. I want to accept the possibility and Lear from it- but at the same time I am considering “label swapping”. How do I know I verified it like that vs someone staged it and took my label with my signs and attached it ?

I don’t know how to proof it to report it. Yet I want to protect my work for possible future events.

QUOTE="Rouelle, post: 20606144, member: 369464"]In full seriousness, is this something you’re dreaming up as a general “what if,” or do you suspect this is happening? If the latter, report your suspicions immediately.[/QUOTE]

 

[Xarelto-10]

You’re right I had that happen before too. I’m short, pill is mixed up etc
Does the guilt rest on the verifying RPH almost always ?

None. Most of the time patient combine bottles without looking (same color pill) then stop by your pharmacy and ask why are 2 different kind of pills in my bottle. One time, an angry customer came in Walmart and showed us a few pills that looked different from the recent one we had refilled for him. After ID them, they were acetaminophen from target!

 

[meltyblend]

Unless you really really pissed someone off, I have a hard time imagining someone going through such an elaborate scheme to get rid of you. Not saying it can't happen but the person sabotaging you is actively putting a patient's health in direct harm. It'll take a very big grudge for someone to go to such length to ensure you get in trouble.

I think the more logical explanation to the label swap is that a mistake has happened. We're human. We get distracted, stressed, careless, fatigued, etc. We are also constantly doing rebills and there are a lot of RTS vials being used for fills. Could be a rebill label swapped or it could be an incorrectly labeled RTS bottle used. I can picture a scenario where a patient has multiple medications rebilled and decided they don't want the OTC one since it's not covered. Tech, being overwhelmed and rushed, accidentally put the wrong label on the wrong vial after reprinting them and hands it to the pharmacist that is equally overwhelmed and rushed. Seeing as it's a rebill of a medication filled on the same day, the pharmacist doesn't think too much of it and verify the meds out on autopilot.

Unless this is a recurring thing that only happens to you, it's a bit of a leap to assume sabotage. Just be vigilant and careful while verifying. That's my 2 cent.

 

[ranger99rx]

I had a situation where an incident took place early December. Discovered on it around 12/8. But not brought to my attention until almost a month latter.

The incident also didn’t make sense to me. I want to accept the possibility and Lear from it- but at the same time I am considering “label swapping”. How do I know I verified it like that vs someone staged it and took my label with my signs and attached it ?

I don’t know how to proof it to report it. Yet I want to protect my work for possible future events.

QUOTE="Rouelle, post: 20606144, member: 369464"]In full seriousness, is this something you’re dreaming up as a general “what if,” or do you suspect this is happening? If the latter, report your suspicions immediately.

[/QUOTE]

Does this pt take both ASA & coreg (whatever the 2 drugs in question?) If yes, then maybe he/she mixed it up by mistake? If no then little investigation. Does your system keep track of your on hand quantity? and subtract when each RX amount being dispensed or add amount being received from the order? If so you can check if anyone has made any on hand adjustment (whether positive or negative) and to see if your on hand for both drugs is correct (or at least close to.) If would be hard to prove if majority on hand quantities are not accurate or you don't have that system in place.

Does your system let you see the time when each task being done to that order and who was doing it? Like when it was input, filled, verified by who? Then can you pull camera at those specific time to show who, when it was filled and you verified. You can see the area where the tech grab drug on the shelf. Let say ASA is on the different isle compare to where coreg is. Hope this will give you some ideas to solve the mystery.

Unfortunately, it always seems we are the one who makes mistake until proven otherwise. That why you have to dig deep what, when, who, how, and why it happened. Good luck.

 

[owlegrad]

Huh. Setting aside the moral/ethical implications of what you are suggesting, wouldn't the saboteur be putting their job at risk to do this? And their license? And in fact be risking jail?

Have you considered that perhaps you are a narcissist? I cannot think of another reasonable explanation for how you can think that anyone hates you so much that they would be willing to risk all that just to possibly get you in trouble. You are not the center of the universe - no one cares that much about you. Occam's Razor suggests that the more likely scenario is that you made the mistake and you are rationalizing it as being a victim of a scheme you cannot combat.

 

[Sine Cura]

The solution is summary termination for anyone found doing it.

 

[JustFillIt]

Okay been wondering in Hospitsl or retail setting if One wants to take a label you signed on and relabel the wrong drug/product etc....there is no way to proof otherwise is there?

I was wondering if there is any type of solution for that ? How do you protect your patieents, and your license ?

Eg: you signed on Asa 325 mg po tabs
Someone “intentionally removed that label with your signature on it and put Coreg tablets and screamed “Med error”

How can one prevent that ?

This would be incredibly malicious and vindictive. Why would someone do this to you?

 

[Deja]

swapping labels? I don't know about hospitals but everything is recorded on the computer when you verify at big retail stores. essentially it's impossible to edit the label after you have verified it without anything been recorded... if they did edit the prescription and change the medication name then they have to verify it again and then their name would be on the label and in the system with a different time stamp

now they can print out a different old label and switch it after you have verified but then that label wouldn't have matched up with the dates in the system and it also would not have scanned at the register

so I'm really confused at how someone could sabotage you by changing labels... it would be easier if they switched out the pill inside the bottle after you verified it... but I highly doubt that's the case....so a more likely scenario is that you just made an mistake

or if you are saying a patient brought in a bottle with a different medication than whats on a label after a month you sold it, then it could be that the patient was combining meds and made an mistake and there are ways to investigate that too if that was the case

 

[Newpharmacist]

I had a situation where an incident took place early December. Discovered on it around 12/8. But not brought to my attention until almost a month latter.

The incident also didn’t make sense to me. I want to accept the possibility and Lear from it- but at the same time I am considering “label swapping”. How do I know I verified it like that vs someone staged it and took my label with my signs and attached it ?

I don’t know how to proof it to report it. Yet I want to protect my work for possible future events.

QUOTE="Rouelle, post: 20606144, member: 369464"]In full seriousness, is this something you’re dreaming up as a general “what if,” or do you suspect this is happening? If the latter, report your suspicions immediately.

[/QUOTE]

By Investing in good pharmacy cameras - and putting at right angles.

At Walmart ,I know you could check the cameras - zoom in and see what Med was pulled and scanned by the tech and filled in the bottle and then again narrowing the time of verification , zoom in to see what was verified .. not completely fool proof but doable ..

For staff and for patients to know that we have checks in place is a huge deterrent.

 

[Xarelto-10]

It is just the situation surrounding the incident that made me question the “what if’s”
Then off course I was more concerned about future solutions than I’m concerned with what had happened.
I’m willing to take responsibility for it and will pay attention humanly possible.
Thanks for your input.


QUOTE="meltyblend, post: 20606510, member: 776296"]Unless you really really pissed someone off, I have a hard time imagining someone going through such an elaborate scheme to get rid of you. Not saying it can't happen but the person sabotaging you is actively putting a patient's health in direct harm. It'll take a very big grudge for someone to go to such length to ensure you get in trouble.

I think the more logical explanation to the label swap is that a mistake has happened. We're human. We get distracted, stressed, careless, fatigued, etc. We are also constantly doing rebills and there are a lot of RTS vials being used for fills. Could be a rebill label swapped or it could be an incorrectly labeled RTS bottle used. I can picture a scenario where a patient has multiple medications rebilled and decided they don't want the OTC one since it's not covered. Tech, being overwhelmed and rushed, accidentally put the wrong label on the wrong vial after reprinting them and hands it to the pharmacist that is equally overwhelmed and rushed. Seeing as it's a rebill of a medication filled on the same day, the pharmacist doesn't think too much of it and verify the meds out on autopilot.

Unless this is a recurring thing that only happens to you, it's a bit of a leap to assume sabotage. Just be vigilant and careful while verifying. That's my 2 cent.[/QUOTE]

 

[Xarelto-10]

At CVS I think the front manager can help guy with that. Actually having cameras “that work” gives yiy a peace of mind.

QUOTE="Newpharmacist, post: 20607576, member: 417866"][/QUOTE]

By Investing in good pharmacy cameras - and putting at right angles.

At Walmart ,I know you could check the cameras - zoom in and see what Med was pulled and scanned by the tech and filled in the bottle and then again narrowing the time of verification , zoom in to see what was verified .. not completely fool proof but doable ..

For staff and for patients to know that we have checks in place is a huge deterrent.[/QUOTE]

 

[Xarelto-10]

Thanks for your comment.

QUOTE="owlegrad, post: 20606964, member: 254429"]Huh. Setting aside the moral/ethical implications of what you are suggesting, wouldn't the saboteur be putting their job at risk to do this? And their license? And in fact be risking jail?

Have you considered that perhaps you are a narcissist? I cannot think of another reasonable explanation for how you can think that anyone hates you so much that they would be willing to risk all that just to possibly get you in trouble. You are not the center of the universe - no one cares that much about you. Occam's Razor suggests that the more likely scenario is that you made the mistake and you are rationalizing it as being a victim of a scheme you cannot combat.[/QUOTE]

 

[CetiAlphaFive]

None. Most of the time patient combine bottles without looking (same color pill) then stop by your pharmacy and ask why are 2 different kind of pills in my bottle. One time, an angry customer came in Walmart and showed us a few pills that looked different from the recent one we had refilled for him. After ID them, they were acetaminophen from target!

Had a pt try that with an NDC we couldn't even order. Lol