Mistakes

[VeeSee]

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How often do you guys find mistakes and misfills?

Not stupid stuff like wrong doctor or a misspelled word or something

I mean stuff like wrong directons, wrong drug, wrong strength, and wrong patient ...

 

[owlegrad]

Sometimes it feels like it is almost daily or at least a few times weekly but in fact there are probably whole months were I don't catch anything. You would think there would be shared reports about this sort of thing.

 

[TheBlaah]

From a hospital perspective: daily. It's usually a night nurse (not a 24/7 pharmacy).

 

[Gombrich12]

Stuff that has gone out to the patient? Probably once every 2-3 months. It really depends on how thorough and accurate the pharmacists are at the store. Pharmacists set the tone on safety and of course are the final check on anything leaving the store.

 

[BenJammin]

What do you mean by "mistakes and misfills"? Are you talking about prescriptions that leave the pharmacy or ones that stay in house but are incorrect? If it's the latter then it's a daily thing.

 

[accordman83]

I think they mean what reaches the patient, that is how I always classify a misfill, I caught 2 in one night by a floater (me being the night Rph I recheck all new day fills)

 

[doublehh03]

At CVS we have to do every mistake that leaves pharmacy (even wrong refills, qty, not mixing...). So pretty quite often. Like my store has like 40+ in the past year.

But "big" mistakes like wrong med, sig, patient... prollie like every few months.

 

[njac]

From a hospital perspective: daily. It's usually a night nurse (not a 24/7 pharmacy).

I found an RN hanging a bag of milrinone that had a nicardipine label on it this week.

So many people got written up for that one.


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[maria1oh]

My last error that I'm aware of was dispensing expired test strips.

 

[owlegrad]

At CVS we have to do every mistake that leaves pharmacy (even wrong refills, qty, not mixing...). So pretty quite often. Like my store has like 40+ in the past year.

But "big" mistakes like wrong med, sig, patient... prollie like every few months.

Actually the examples you gave are specifically listed as being exempt from the mandatory reporting process. I think you need to double-check the policy.

In fact I don't think the reporting form even has wrong quantity or not mixed as one of the reporting options.

Double check me but I think the mandatory reporting is for wrong patient, wrong strength, wrong drug, or wrong directions.

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[doublehh03]

Actually the examples you gave are specifically listed as being exempt from the mandatory reporting process. I think you need to double-check the policy.

In fact I don't think the reporting form even has wrong quantity or not mixed as one of the reporting options.

Double check me but I think the mandatory reporting is for wrong patient, wrong strength, wrong drug, or wrong directions.

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Well, not technically. Sure, you most likely will get away with them if patients didn't complain. To be on safer side, you should report all. If the patient brings it up, you should file an incident report (even if wrong packaging for instance or wrong quantity). A pharmacist in a neighboring district was fired b/c she didn't write up an incident report for wrong quantity dispensed (a patient was short and complained to corporate and corporate dug deep). CVS has a no tolerance policy on this FYI. I confirmed this with my sup.

You can file IR electronically for wrong dispensing/packaging and not mixing.

 

[owlegrad]

Well, not technically. Sure, you most likely will get away with them if patients didn't complain. To be on safer side, you should report all. If the patient brings it up, you should file an incident report (even if wrong packaging for instance or wrong quantity). A pharmacist in a neighboring district was fired b/c she didn't write up an incident report for wrong quantity dispensed (a patient was short and complained to corporate and corporate dug deep). CVS has a no tolerance policy on this FYI. I confirmed this with my sup.

You can file IR electronically for wrong dispensing/packaging and not mixing.

I just pulled up the policy on the quality assurance website and it says you only have to report wrong quantity or wrong prescriber if it impacted the health outcome of the patient. That is straight off the QA website. The fired RPH should sue assuming there is not more to the story that we do not know.

I was wrong about reconstituting though that is a mandatory report and it is available on the form. Obviously I haven't kept up with the policy changes around that, when I did the reporting module years ago there were a lot fewer things that had to be reported.

I agree that the best policy is to just report everything however that's not required by company policy.

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[VeeSee]

I mean stuff that actually leaves and reaches the customer/patient


How does wrong prescriber hurt anybody lol

Only way I see prescriber being an issue is from a legal standpoint with controlled medications or with scope of practice but other than that wrong prescriber lol

 

[Digsbe]

I mean stuff that actually leaves and reaches the customer/patient


How does wrong prescriber hurt anybody lol

Only way I see prescriber being an issue is from a legal standpoint with controlled medications or with scope of practice but other than that wrong prescriber lol

It can impact refill requests. If the pharmacy sends refill requests or has a fax system that does that it will go to the wrong provider's office. Even if it doesn't "hurt" anyone it still complicates things and insurance companies will sure as heck audit for that because they can see it as an excuse to refuse payment.

 

[ancienbon]

Well, not technically. Sure, you most likely will get away with them if patients didn't complain. To be on safer side, you should report all. If the patient brings it up, you should file an incident report (even if wrong packaging for instance or wrong quantity). A pharmacist in a neighboring district was fired b/c she didn't write up an incident report for wrong quantity dispensed (a patient was short and complained to corporate and corporate dug deep). CVS has a no tolerance policy on this FYI. I confirmed this with my sup.

You can file IR electronically for wrong dispensing/packaging and not mixing.

i dont think so. There has to be more to the story.

 

[doublehh03]

I just pulled up the policy on the quality assurance website and it says you only have to report wrong quantity or wrong prescriber if it impacted the health outcome of the patient. That is straight off the QA website. The fired RPH should sue assuming there is not more to the story that we do not know.

I was wrong about reconstituting though that is a mandatory report and it is available on the form. Obviously I haven't kept up with the policy changes around that, when I did the reporting module years ago there were a lot fewer things that had to be reported.

I agree that the best policy is to just report everything however that's not required by company policy.

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Well if the patient complains (meaning it impacted their health b/c they complained - interruption of therapy lol), a report had to be done. That RPH didn't do it. To be on the safer side, if the patient brings it up, file it.

 

[trailerpark]

My last error that I'm aware of was dispensing expired test strips.

How the heck did that happen?


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[Sine Cura]

CVS labels automatically print a "discard after" date of one year after fill date. It's up to the pharmacist to check exp date

Also wrong prescriber is considered a HIPAA violation so it is just easier to have the right prescriber and office in the first place.

TBH the most frequent mistakes I see are wrong inhaler package size or wrong injectable package size because techs and pharmacists don't know **** about product selection and are just focused on technical correctness instead of "does this script make any ****ing sense." Like quantity 17g is ****ing Proair HFA x2 FFS.

 

[wagrxm2000]

CVS labels automatically print a "discard after" date of one year after fill date. It's up to the pharmacist to check exp date

Also wrong prescriber is considered a HIPAA violation so it is just easier to have the right prescriber and office in the first place.

TBH the most frequent mistakes I see are wrong inhaler package size or wrong injectable package size because techs and pharmacists don't know **** about product selection and are just focused on technical correctness instead of "does this script make any ****ing sense." Like quantity 17g is ****ing Proair HFA x2 FFS.

At Walgreens you just put 1- for one package.

 

[sosoo]

at CVS u get away with anything. wrong opioids dispensed and patient got hospitalized? dispensing drugs for chinese lady with script specified for american lady? they all get hospitalized, and the district sup will tell u to complete the incident report and end of discussion. they could care less what happen. or even how frequent it happen. cvs does not care about errors....period!

 

[Sine Cura]

They care about errors if they want to fire you

 

[doublehh03]

at CVS u get away with anything. wrong opioids dispensed and patient got hospitalized? dispensing drugs for chinese lady with script specified for american lady? they all get hospitalized, and the district sup will tell u to complete the incident report and end of discussion. they could care less what happen. or even how frequent it happen. cvs does not care about errors....period!

If you have too many incident reports, you will be monitored. I don't know what "too many" is but I know a few RPHs who were being monitored for excessive incident reports under their names.

Obviously, it isn't a big deal at CVS as it should be I believe. I hate making mistakes, esp. big mistakes like wrong name/drug/strength/sig...

At my store, we file everything so I can monitor the trends.

 

[maria1oh]

At Walgreens you just put 1- for one package.

At cvs you can put 1p and it populates 1 package size. 2p for two packages. Cvs also has multi package scan so if you put 2p as quantity the scanner will make you scan two packages during product

 

[lane one]

at CVS u get away with anything. wrong opioids dispensed and patient got hospitalized? dispensing drugs for chinese lady with script specified for american lady? they all get hospitalized, and the district sup will tell u to complete the incident report and end of discussion. they could care less what happen. or even how frequent it happen. cvs does not care about errors....period!

As Sine Cura pointed out, they'll use errors as justification to terminate you, but the company sees them as an expense and nothing more. If they really cared about dispensing errors they would have metrics to measure and improve the cause of those errors. Currently all the metrics ultimately aim to improve profitability (customer service, waste, inventory etc.). On a side note, they have a to have that data whether or not they report it and release it. I would love to see if there is a correlation with dispensing errors and script/tech hour ratio. If they really cared about dispensing errors they would be looking at that stuff. As long they can make more money by dominating the market than they lose through the occasional lawsuit, they'll keep plugging away.

 

[owlegrad]

As Sine Cura pointed out, they'll use errors as justification to terminate you, but the company sees them as an expense and nothing more. If they really cared about dispensing errors they would have metrics to measure and improve the cause of those errors. Currently all the metrics ultimately aim to improve profitability (customer service, waste, inventory etc.). On a side note, they have a to have that data whether or not they report it and release it. I would love to see if there is a correlation with dispensing errors and script/tech hour ratio. If they really cared about dispensing errors they would be looking at that stuff. As long they can make more money by dominating the market than they lose through the occasional lawsuit, they'll keep plugging away.

Accuracy bypass scan rate is about the only metric I can think of that measures safety.

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[VeeSee]

Well, not technically. Sure, you most likely will get away with them if patients didn't complain. To be on safer side, you should report all. If the patient brings it up, you should file an incident report (even if wrong packaging for instance or wrong quantity). A pharmacist in a neighboring district was fired b/c she didn't write up an incident report for wrong quantity dispensed (a patient was short and complained to corporate and corporate dug deep). CVS has a no tolerance policy on this FYI. I confirmed this with my sup.

You can file IR electronically for wrong dispensing/packaging and not mixing.

So what if it didn't leave the store? Do you have to file an IR at CVS if the patient checks to see while in the store that they got the right number of inhalers or packages and they bring it right back?

 

[lidocainejelly]

On the subject of misfills.... this has been weighing on my mind. Recently I was on the discovering end of a mistake where an RPH bypassed some serious DUR warnings and a drug was dispensed to be taken in a potentially very dangerous dose for a child. There was no error with typing or filling -- the MD sent the rx over that way. But the MD clearly made a mistake/is an idiot. I was on the front lines dealing with the (understandably) upset family. I never filed a true incidence report, I was just freaking out that day and called the verifying rph of that rx and my Sup to tell them about it. This probably has the potential to go legal which is another story but if I wasn't the verifying rph do you think I could still get in trouble with my employer for not doing a true incidence report the moment I discovered?

 

[VeeSee]

On the subject of misfills.... this has been weighing on my mind. Recently I was on the discovering end of a mistake where an RPH bypassed some serious DUR warnings and a drug was dispensed to be taken in a potentially very dangerous dose for a child. There was no error with typing or filling -- the MD sent the rx over that way. But the MD clearly made a mistake/is an idiot. I was on the front lines dealing with the (understandably) upset family. I never filed a true incidence report, I was just freaking out that day and called the verifying rph of that rx and my Sup to tell them about it. This probably has the potential to go legal which is another story but if I wasn't the verifying rph do you think I could still get in trouble with my employer for not doing a true incidence report the moment I discovered?

why don't you do it now?

Its easy to get into the habit of just overriding all DURs without caring but that is the reason why you are there ... to go through the DUR and make sure it's safe for the patient to get the medicine

both the MD and verifying RPh need to take responsibility

 

[wagrxm2000]

On the subject of misfills.... this has been weighing on my mind. Recently I was on the discovering end of a mistake where an RPH bypassed some serious DUR warnings and a drug was dispensed to be taken in a potentially very dangerous dose for a child. There was no error with typing or filling -- the MD sent the rx over that way. But the MD clearly made a mistake/is an idiot. I was on the front lines dealing with the (understandably) upset family. I never filed a true incidence report, I was just freaking out that day and called the verifying rph of that rx and my Sup to tell them about it. This probably has the potential to go legal which is another story but if I wasn't the verifying rph do you think I could still get in trouble with my employer for not doing a true incidence report the moment I discovered?

What was the drug?

Unfortunately these are the hardest decisions. There's a good chance even after calling the md and explaining the potential issues the md will still not change his dosing.

 

[VeeSee]

What was the drug?

Unfortunately these are the hardest decisions. There's a good chance even after calling the md and explaining the potential issues the md will still not change his dosing.

If you know the dose is wrong then don't dispense it

 

[maria1oh]

I read in an email from supervisor that if patient was suppose to receive 60 tablets but only received 30 then no misfill report needed unless patient was harmed.

 

[doublehh03]

So what if it didn't leave the store? Do you have to file an IR at CVS if the patient checks to see while in the store that they got the right number of inhalers or packages and they bring it right back?

At our store, if the customers bring it up, it's an error. So if we just rung them up and they pointed it out, I'll file it.

 

[doublehh03]

On the subject of misfills.... this has been weighing on my mind. Recently I was on the discovering end of a mistake where an RPH bypassed some serious DUR warnings and a drug was dispensed to be taken in a potentially very dangerous dose for a child. There was no error with typing or filling -- the MD sent the rx over that way. But the MD clearly made a mistake/is an idiot. I was on the front lines dealing with the (understandably) upset family. I never filed a true incidence report, I was just freaking out that day and called the verifying rph of that rx and my Sup to tell them about it. This probably has the potential to go legal which is another story but if I wasn't the verifying rph do you think I could still get in trouble with my employer for not doing a true incidence report the moment I discovered?

The RPH on duty MUST be the one who has to file it. If you don't do it, you will get fired if corporate dug deep (which they will b/c there are legal implications). So file it ASAP.

 

[CetiAlphaFive]

If you know the dose is wrong then don't dispense it

This.
I don't see why some pharmacists think scribbling "OK per Dr. _______ 4/12/16 __" somehow magically absolves them of any responsibility.

Sure, it's uncomfortable, but we have to be patient advocates.

If the M.D. just sends the patient to another pharmacy you've done everything you could.

 

[BenJammin]

This.
I don't see why some pharmacists think scribbling "OK per Dr. _______ 4/12/16 __" somehow magically absolves them of any responsibility.

Sure, it's uncomfortable, but we have to be patient advocates.

If the M.D. just sends the patient to another pharmacy you've done everything you could.

That's probably the most confusing thing that retail pharmacists do. Of course the doctor is going to say the dose is okay, they were the ones who wrote it!

 

[Caffeine QAM]

If the M.D. just sends the patient to another pharmacy you've done everything you could

The hope would be that the RPh at the next pharmacy would also see the problem as well and also contact the MD and refuse to fill it. After hearing from 3-5 pharmacists that they won't fill the prescription, and perhaps with the addition of the patient complaining that they can't get the medication, maybe the MD will get the idea that there's something wrong with it. May also being refused to have their meds filled by 5 pharmacies might give the patient the idea that the pharmacists are actually watching out for them - though there's the occasional patient that may think there's a conspiracy between pharmacists (as if pharmacists had the time and wherewithal to contact every other pharmacy to tell them not to fill a med for this patient) to sabotage them and deny them medication. They may sometimes resort to claims they are being discriminated against.

Of course, the one RPh that goes ahead and does the "OK per MD" thing completely sabotages the efforts of the pharmacist(s) before them by reinforcing the idea that you can just go to another pharmacy, completely ignoring the fact that there's a problem with the prescription.

 

[BidingMyTime]

That's probably the most confusing thing that retail pharmacists do. Of course the doctor is going to say the dose is okay, they were the ones who wrote it!

Actually, the majority of time when I've called the doctor, the doctor either admitted s/he made a mistake and changed it (or wouldn't admit they made a mistake but said "whatever, change it to whatever you want.) or the doctor explained the reasoning behind his/her dosing, so then I was comfortable with filling the prescription. Only twice in like 25 years have I had a doctor refuse to change a clearly wrong dosing....1 case would have most certainly been fatal and I refuse to fill the script and told the mother why (this was retail), the other I couldn't see resulting in any patient harm but was clearly not economical so I filled it and reported it the next day to my pharmacy director (this was hospital)

Most doctors aren't idiots, if they messed up, they will want to change the script, and if there are extenuating circumstances they will be able to explain them.

 

[owlegrad]

Actually, the majority of time when I've called the doctor, the doctor either admitted s/he made a mistake and changed it (or wouldn't admit they made a mistake but said "whatever, change it to whatever you want.) or the doctor explained the reasoning behind his/her dosing, so then I was comfortable with filling the prescription. Only twice in like 25 years have I had a doctor refuse to change a clearly wrong dosing....1 case would have most certainly been fatal and I refuse to fill the script and told the mother why (this was retail), the other I couldn't see resulting in any patient harm but was clearly not economical so I filled it and reported it the next day to my pharmacy director (this was hospital)

Most doctors aren't idiots, if they messed up, they will want to change the script, and if there are extenuating circumstances they will be able to explain them.

I don't have 25 years of experience (!) but my experience has been similar. I can't really think of any instance off the top of my head where once I actually reached the prescriber we were not able to work it out. I have had plenty of "the doctor said to fill it is as" responses from office help though. Those are annoying AF. I am not calling to get the offices permission to fill the script, I am calling to inform the doctor that this script is potentially life-threatening and I am not going to be able to fill it without some discussion of why it is appropriate. Plenty of times once I get the doctor they thank me for bringing the issue to their attention and I can only think of a few times where the prescriber was rude to me after explaining their reasoning. Most are quite gracious.

 

[rph3664]

I found an RN hanging a bag of milrinone that had a nicardipine label on it this week.

So many people got written up for that one.


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My BFF gave a TDaP instead of a Td last week, and a couple days ago, his boss told him that he was a disgrace to the department. He had an interview with an independent earlier this week, and if he gets the offer (he should; he's pretty sure he's the only one who applied) he's going to take it.

 

[fcrc]

That I know of, I haven't dispensed anything incorrectly since I started working at an independent (5+ months) since I actually have the time to really check--not because it's not busy, but because we are adequately staffed and I don't even have to touch the register. At my former chain, I averaged about 1 error every month and a half, and all were caught from the first refill and none were life-threatening (IR vs. ER, wrong multivitamin, wrong Contour vs. Contour Next...which they stupidly count as an error). Chain environments are not conducive to patient safety in my opinion...I admit it was my fault for not preventing the errors, but that fault is definitely shared with the company

 

[Van zandt]

Id have to respectfully disagree to the comment about CVS system only revolves around profit and not safety. Coming from a small pharmacy and going to CVS I really feel that the system has a lot of safety measures put in place to avoid these errors from filing with wrong prescriber to dispensing wrong drug. The system does have its glitches however it does prevent a lot of mistakes from happening. At the end of the day the major responsibility is placed on us as the pharmacists and with or without a system it is our job to make sure everything is correct and we shouldn't solely rely on as system to do our duty. There is no system more accurate than your own eyes and hands.

 

[zelman]

Id have to respectfully disagree to the comment about CVS system only revolves around profit and not safety. Coming from a small pharmacy and going to CVS I really feel that the system has a lot of safety measures put in place to avoid these errors from filing with wrong prescriber to dispensing wrong drug. The system does have its glitches however it does prevent a lot of mistakes from happening. At the end of the day the major responsibility is placed on us as the pharmacists and with or without a system it is our job to make sure everything is correct and we shouldn't solely rely on as system to do our duty. There is no system more accurate than your own eyes and hands.

If CVS operated an ICU everyone would die. They only get away with what they do because their patients are healthy enough to be outpatients. The computer system is okay, but the staffing and culture are not.

 

[ldiot]

How many reports do you have to make before you have to take a class/go on probation? How long does it take for reports to "expire" in terms of counting towards having to take the class? At CVS

 

[zelman]

How many reports do you have to make before you have to take a class/go on probation? How long does it take for reports to "expire" in terms of counting towards having to take the class? At CVS

That info is not known outside of corporate IIRC. I had a buddy on double secret probation for a while, but I don't think he knew exactly why he got there.

 

[Van zandt]

I

If CVS operated an ICU everyone would die. They only get away with what they do because their patients are healthy enough to be outpatients. The computer system is okay, but the staffing and culture are not.

I'm not sure I understand the direction of your comment.
Yeah I don't think an ICU would be a good idea for CVS nor would any other corporate pharmacy company. However like you said no one is sick or dying. We're just filling scripts. Were checking bottles and making sure all legal requirements are met in regards to correct drug to proper prescriber dea. I agree I have worked with a lot of incompetent staff and no I don't agree with all the decisions corporate makes but I think the system and workflow really helps to our benefit. But again just my opinion.

 

[trailerpark]

What's double secret probation?


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[ldiot]

That info is not known outside of corporate IIRC. I had a buddy on double secret probation for a while, but I don't think he knew exactly why he got there.

Do you have any guess? Are we talking 3 a year or 20 a year? Also wtf is double secret probation?

 

[zelman]

What's double secret probation?


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...sigh...uncultured children...

Do you have any guess? Are we talking 3 a year or 20 a year? Also wtf is double secret probation?

It was like 3 errors that met certain criteria in 12 months or something. Then you get out by having zero errors in 6 months?

 

[zelman]

I
I'm not sure I understand the direction of your comment.
Yeah I don't think an ICU would be a good idea for CVS nor would any other corporate pharmacy company. However like you said no one is sick or dying. We're just filling scripts. Were checking bottles and making sure all legal requirements are met in regards to correct drug to proper prescriber dea. I agree I have worked with a lot of incompetent staff and no I don't agree with all the decisions corporate makes but I think the system and workflow really helps to our benefit. But again just my opinion.

My point is that CVS has policies and staffing meant to maximize profits, not provide good service or prevent errors. Every time there are record profits tech hours get cut. Every time an RX count record is broken pharmacists are given a new series of phone calls to make. It's just balancing profitability and liability with healthcare as a by-product.

 

[ldiot]

...sigh...uncultured children...




It was like 3 errors that met certain criteria in 12 months or something. Then you get out by having zero errors in 6 months?

Thanks for the info. I'm surprised it's only ~3 errors seeing as people on this forum are saying single stores have 40+ incident reports a year