Learning Lesson--I made a mistake!

[gaba101]

After having read that 20/20 story and watched the show, I thought this would be an interesting thread where practicing pharmacists (and licensed intern pharmacists) can post the following so the rest of us can learn. Of course, it does not mean if you know what is posted here, you will be error-free. We are human and we make mistakes but sharing your mistakes with others can hopefully provide some hindsight for others so they, too, do not make the same mistake as you. So post the following:

1) mistake made
2) Why was the mistake made
3) Steps to prevent mistake from occuring/what you learned

Please post in this format so that it is an easy read for everyone.

Rule--please do not criticize others for the mistake made or ridicule them. The purpose is for everyone to LEARN FROM the mistake.

---

Members don't see this ad.

 

[gaba101]

1) Handed medication to wrong patient ("X")

2) Busy day and it was around lunch time closing. 4 customers crowded around the pick-up area. Patient "X" didn't want one of his/her meds. So I had to void the register, RTS the unwanted med. Another bagged medication was sitting by the register and I grabbed the wrong one to ring up. Patient swiped credit card and realized s/he paid for someone else's medication. Patient was thankfully not mad but happy she did not walk away with the wrong medication!

3) Lesson learned: I don't care how mad some people get for waiting longer because the person in front of them is taking forever. 1 customer/party at the pick up window at a time. Everyone else wait in in a line BEHIND each other--do NOT crowd around the pick-up area. And of course, always double check names and medication bottles at each step before handing drug to patient.

 

[WestTXisGr8]

Well, in my 2 weeks of working as a Tech (at CVS), so far no mistakes (of course I'm not able to do much yet either). However, I did input a woman's script and pulled the medication. Pharmacist took it from there. But when she pulled up to the the drive-up to pick up she looked at it and said I gave her the wrong medication. She can't take the medication I gave her. I was very apologetic and told her I would find out where the error was immediately. We (Pharmacist, other tech and myself) pulled the original script and it was writen specifically for the medication we gave her.

Went back to the window and told her that was the medication she was prescribed by the doctor. She became irrate. Told me the doctor was her best friend and the doctor knows she can't take this medication and would NEVER prescribe it to her. I handed her the original script from the doctor. She told me to fill it with a different medicine. Pharmacist told her we needed the doctor to call us and tell us to fill it with a different med. She was very irrate and kept saying (even though the doctor's written script was in her hand in front of her face) that the doctor would have never prescribed her this.

She was NOT going to be convinced by any of us that the doctor actually DID prescribe it to her. It apparently was a huge consipiracy on our part. Got it worked out, dr. called in a different med. But she wasn't happy about "our" mistake and the time it took out of her day when she drove off.

Looking back now, I definitely should have put a note in her file to NEVER EVER fill a script for that original medication for her. But I'm still learning. I've never worked in a pharmacy before, so this is a huge learning curve for me.

And other than a few irrational people, and a couple of "addicts" who go haywire when we can't get the insurance to pay for their hydrocodone on an early refill, I'm really enjoying the job.