Misfill

[phamlife]

Had my first misfill. Not even sure if its considered a misfill. Someone else’s drug was bagged with the patient’s bag. I may have been distracted, not sure exactly how that happened. The tech who checked patient out did not scan out all the tags and didnt catch the error at the register.

According the patient, she did not take any of the drug and returned it. Would this be considered a misfill and how does your pharmacy handle something like this?

---

Members don't see this ad.

 

[ValeRx]

It's a HIPAA breach and a misfill.

 

[Xenophylia]

Yeah the HIPAA part is the bad part. Depends on your employer how they will handle but I believe both parties need to be notified....

 

[phamlife]

Yeah the HIPAA part is the bad part. Depends on your employer how they will handle but I believe both parties need to be notified....

All parties were informed. Everyone is okay and were understanding. They knew it was a mistake. I guess im just concerned since its my first misfill.

 

[Xenophylia]

Yeah if that was already done that's the worst of it. It happens. I've seen pharmacists not report such incidents and get fired for covering it up so it's good you came clean about what happened. Mistakes are the price of doing business unfortunately.

 

[ValeRx]

All parties were informed. Everyone is okay and were understanding. They knew it was a mistake. I guess im just concerned since its my first misfill.

I'm pretty sure there's an actual HIPAA breach form that needs to be filled out and submitted. You can't just call both people, say whoops, and that's the end of it.

 

[vinapharm]

Had my first misfill. Not even sure if its considered a misfill. Someone else’s drug was bagged with the patient’s bag. I may have been distracted, not sure exactly how that happened. The tech who checked patient out did not scan out all the tags and didnt catch the error at the register.

According the patient, she did not take any of the drug and returned it. Would this be considered a misfill and how does your pharmacy handle something like this?

Relax, as long as patient is not harmed. Everything will be alright. Not sure if you are new Rph into the retail world but if you work long enough. You know that as long as patient is ok, then you will be ok

 

[RXDOC1986]

Had my first misfill. Not even sure if its considered a misfill. Someone else’s drug was bagged with the patient’s bag. I may have been distracted, not sure exactly how that happened. The tech who checked patient out did not scan out all the tags and didnt catch the error at the register.

According the patient, she did not take any of the drug and returned it. Would this be considered a misfill and how does your pharmacy handle something like this?

The fact that you don't even see it as a misfill, is the bigger problem. A tech does not get paid to discover your error. This was your first, don't point fingers at a tech, own it, and move on. I promise you it will not be your last.
Pharmacist for 36 years

 

[phamlife]

The fact that you don't even see it as a misfill, is the bigger problem. A tech does not get paid to discover your error. This was your first, don't point fingers at a tech, own it, and move on. I promise you it will not be your last.
Pharmacist for 36 years

The fact that you sound very condescending to someone who was simply asking for an advice tells me all I have to know about you as a person. Geez to think about everyone that had to deal with you for 36 years, makes me want to leave this profession even more lol

I was not blaming or pointing fingers at the tech for the error. I was stating that it couldve been caught during POS had all the tags been scanned. When I had to fill out the misfill report, that had to be included and both myself and the tech were considered responsible for the misfill.

Also, please read. I admitted that it was a misfill.

 

[MountainPharmD]

Not to belabor the point but...A prescription misfill occurs when a prescription is filled with the wrong medication or dosage. Did that happen in this case? Someone else’s drug bagged in another patients bag is an error for sure but its not a misfill. In my pharmacy the clerk or tech that rings the patient up is responsible for matching the drug to the label receipt to the patients date of birth. This error would be written up on the tech or clerk who sold the medicine. It would be logged in as an accidental HIPAA violation and forwarded to the privacy officer (me) for investigation.

 

[JustFillIt]

Not to belabor the point but...A prescription misfill occurs when a prescription is filled with the wrong medication or dosage. Did that happen in this case? Someone else’s drug bagged in another patients bag is an error for sure but its not a misfill. In my pharmacy the clerk or tech that rings the patient up is responsible for matching the drug to the label receipt to the patients date of birth. This error would be written up on the tech or clerk who sold the medicine. It would be logged in as an accidental HIPAA violation and forwarded to the privacy officer (me) for investigation.

This is how I have always seen it.

When I was a PIC - bagging the Rx was a technician function. It was then mandatory that the tech match up all bottles and all paperwork at the counter with pickup. Then they Cross checked all Rx at the counter. If there was ever a wrong Rx that went out the door it was very clearly the technicians fault. Not the pharmacist

 

[Sunshine98*]

Also be aware that a tech could possibly care less is a mistake is made. Ive seen one have the attitude that they would come after a pharmacist first, etc. Its sad.

 

[vinapharm]

Also be aware that a tech could possibly care less is a mistake is made. Ive seen one have the attitude that they would come after a pharmacist first, etc. Its sad.

Oi , i hate that kind of attitude of a tech. I had one too and jeez, can't stand her at all. Lucky I quit that company. Now where i am is much better.

 

[steveysmith54]

Unfortunately this happens a lot in busy pharmacies, or actually in all retail pharmacies.
don’t worry about it and good job doing everything by the book.
I have to say I don’t miss retail pharmacy.

 

[Charcoales]

Make sure to do an official incident report and HIPAA releases. If you don't highly likely to be fired.

 

[mrbrklyn]

The fact that you don't even see it as a misfill, is the bigger problem. A tech does not get paid to discover your error.

There is a lot to disagree with here. First, medication errors come in varieties and you can review them on the JACHO and FDA site, but that is not the bigger problem, and he is right. Technically is it not a misfill. It is a wrong patient and bagging problem which is much more common. More importantly, you are 100% wrong about the statement about the tech. The Pharmacists sets up systems and checks and balances to prevent errors, and this is likely the most common of such errors. The tech 100% get paid to catch this error, as does the cashier.. AND the Pharmacist ...

It is required by CMS standards to record the error in a medication error log and do a review of the systems to assure that they are working, which they DIDN'T in this case. If the cashier gave out the drug without doing a complete scan of the labels, then that requires an incident report and employee counseling, assuming that was a in fact a failure. Additionally, evaluation needs to be made as to how that drug got into the wrong bag, and if the pace is too fast for the pharmacy/pharmacist, and if proper breaks were taken, etc etc. In the end, however, activities that depend on a single source of verification will fail all the time at unacceptable rates. In this case, there was already more than one check point and STILL the error got past the system.

Root Cause Analysis and Medical Error Prevention - StatPearls - NCBI Bookshelf

 

[mrbrklyn]

Medication Errors | CMS Compliance Group

cmscompliancegroup.com

 

[Dred Pirate]

Oi , i hate that kind of attitude of a tech. I had one too and jeez, can't stand her at all. Lucky I quit that company. Now where i am is much better.

I had a friend who had a tech that admitted to intentionally making mistakes, just to see if the pharmacist caught them. Needless to say, they were relieved of their duties.

 

[alpha12]

I had a friend who had a tech that admitted to intentionally making mistakes, just to see if the pharmacist caught them. Needless to say, they were relieved of their duties.

Lol. Why would they admit that?

 

[Dred Pirate]

Lol. Why would they admit that?

They weren’t the sharpest crayon in the box. I think they told another tech who told my friend.

 

[BidingMyTime]

I had a friend who had a tech that admitted to intentionally making mistakes, just to see if the pharmacist caught them. Needless to say, they were relieved of their duties.

Back when med boxes were the thing, I worked at a toxic place where the techs would accuse each other of messing with med boxes after another tech filled them (but before the pharmacist checked them,) just to make it look like the other tech was making lots of errors. Never proven, but seeing the toxicity in other areas, I fully believed it was happening. I left that place as I could.

 

[Chrish]

I had a friend who had a tech that admitted to intentionally making mistakes, just to see if the pharmacist caught them. Needless to say, they were relieved of their duties.

Similar incidence. Techs admitted making mistakes on purpose to get the manager fired since they didn’t like him. Were stupid enough to admit it in front of new PIC just to brag.

Were gone after new Pic reported them.

 

[GrandTheftAutumn]

Similar incidence. Techs admitted making mistakes on purpose to get the manager fired since they didn’t like him. Were stupid enough to admit it in front of new PIC just to brag.

Were gone after new Pic reported them.

When I catch technicians' mistakes, sometimes they'd tell me that they were just testing me.
Thus far I've passed all their tests as far as I know.

 

[alpha12]

When I catch technicians' mistakes, sometimes they'd tell me that they were just testing me.
Thus far I've passed all their tests as far as I know.

Maybe it’s a joke?

 

[GrandTheftAutumn]

Maybe it’s a joke?

Yes Sherlock...

 

[WorthlessOxygen]

Yes Sherlock...

Seems weird to throw that anecdote into a discussion about techs intentionally making mistakes and then being annoyed when it isn't clearly read as a joke

 

[alpha12]

Yes Sherlock...

Looks like I wasn’t the only one who thought you were being serious.