mistakes

[ShannonIV]

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I am wondering how often you as a pharmacist have made a mistake? I am especially interested in what is "normal" and the rates of errors in hospital pharmacists. Thanks!

 

[Old Timer]

Please define mistake. And I want a precise definition of an error or a list of items that might constitute an error. Is it an error it is:

• Caught by the pharmacist before the patient gets it.
• Caught by the patient before they take it.

There are errors that are technical errors that are not clinical errors but would still be considered an error.

Would placing the wrong physician's name on the label be considered an error?

What about an incorrect number of refills?

 

[Epic]

We used to track order entry errors by pharmacists.

The # or errors ranged from 10 to 50 per month per pharmcist with # of orders ranging from 2000 to 10000 per month per pharmacist. Most of the errors were caught before it reached the patient.

 

[ShannonIV]

errors that are:
caught by the patient (or nurse if in hosp) before they take it
and
reaches patient

 

[Old Timer]

Would you consider it to be an error if the patient received Maxzide instead of Dyazide or Atarax instead of Vistaril?

The answer to your question is the error rate for real errors is lower than most people think.

I speak only from a retail experience. I have no hospital experience so I am not qualified to comment.

The rate posted by Epic of 1 error per 200 orders is higher than anything I have experienced. That is at volume ranges from 600 per week to 4000 per week. I do know the higher the volume the more errors. I do not have data at where the tipping point is. There are so many variables:

# of Pharmacists
# of Techs
Quality of the techs
The system employed

It's hard to control out all of the variables.

 

[sdn1977]

errors that are:
caught by the patient (or nurse if in hosp) before they take it
and
reaches patient

Shannon - I'd have to agree with Epic - the error rate can be as low as 0.1% to 3-4%. Look into ISMP - Institute of Safe Medication Practices. That is the place where hospital pharmacists report drug errors.

If you're in a "good" facility - in which the error is considered a "learning" situation, the error is publicized (without specific info about who did it & the actual pt) - so it becomes a learning situation.

Often, errors in hospitals which are attributable to pharmacists (which is everything which comes out of the pharmacy...even if a tech did it), is tied to "systems" or "environmental circumstances".

That means that programming the standard computer order sets (which Tussionex is busy doing as we speak) is so very important! A decimal here or there, an error in q4h vs q2h can be instrumental in causing an error, partially because we do such repetitive stuff over & over & over again. You may not be aware, but a post-op CABG pt may come out of the OR with 30 drug orders which must be entered & we may have 4 or 5 CABG pts on any given day.

So - its easy to just accept the "standard" CABG orders....this is entirely different than an outpt pharmacy when you are presented with one script at a time (now - it may have 5 rxs on it, but it is not "routine").

So - our errors can be frequent & often due to repetitiveness. Additionally, the environment plays a HUGE part. Studies have shown that poor lighting, poor computer placement, alternative "sounds" (like music) which impacts areas in which calculations take place all contribute to error rates.

In a hospital, yes....dispensing Maxzide instead of Dyazide (or the generic equivalents would be an error)...but we have therapeutic equivalents which allow us to substitute Vistaril for Atarax (we actually have neither - we have the generic equivalents which are interchangeable).

Hospital rules are different with respect to what you can & cannot substitute for a particular drug based on P&T committee decisions...so those substitutes are not considered errors. Likewise, in either environment - hospital or retail, if you let a drug dosage error thru without proper justification & documentation, it is a drug error.

However, hospitals are more strict in the sense that a drug error has taken place if the pt did not receive a drug within a particular time frame - again...the right drug to the right pt @ the right time.

When I work retail, I'm also in a tremendously supportive environment & they also publish common errors quarterly. It is an educational tool to try to change behavior & minimize the possibillty of errors.

Just this week, someone had put Lexapro on the fast mover shelf - it just so happened it was smack dab next to Lipitor. Well - I don't care how many depressed pts we have - that goes back on the shelf. The chances of mixing those two up is way too great - bottles are similar (at fast glance), strengths are similar. Just not worth it!

Personally, most of my own errors are caught before reacing patients, but some have. Since I supervise pharmacists, I always think before reacting that I could be that person, but for the grace of God (or having lunch, taking a day off, etc...) & I try to help the individual think back to what circumstances caused them to be less careful than they are normally.

There is no "normal". You strive for none, but you will have some. Just do the very best you can on any given day & find the resources you have available to you at all time - day or night.

Good luck!

 

[ShannonIV]

oops replied in wrong thread

 

[tussionex]

the trick with standard order sets is to be aware of what the standard is, and then notice the tweaks that each MD puts on the orders! everyone adjusts a time, a frequency, a dose...etc...

we substitute all the time....i'm also currently trying to get our computer system to automatically offer the substitutions on order entry to the entering pharmacist.
also, things like refills [which aren't relevant in inpatient settings] or MD's name [we just rely on the ADT info that transmits the physician's names to our RX system] are not things we consider errors. not getting a med to a patient in a proper, timely manner is more likely to be written up as an "error"

tussionex is currently editing 2 different trainwrecks of formulary files, to make them pretty for pyxis. next up is setting up orders sets and kits! weeee!

 

[Epic]

tussionex is currently editing 2 different trainwrecks of formulary files, to make them pretty for pyxis. next up is setting up orders sets and kits! weeee!

What u doing...file dump into Pyxis when the interface goes live?

 

[tussionex]

dumping into test system. testing interface, testing charges, testing profiles.
basically trying to break the test system so we can tweak the live one!

 

[Epic]

dumping into test system. testing interface, testing charges, testing profiles.
basically trying to break the test system so we can tweak the live one!

Awesomeness.. somebody who can talk automation.. That's hot!😍

BTW...if you're like "the" person working on it... you better shut off your phone at night.. cuz when Pyxis goes down, instead of calling the 1-800# plastered all over Pyxis...they'll be calling Tussi ...

 

[tussionex]

i have already threatened the overnight technicians with quick death should they do that!

 

[Epic]

i have already threatened the overnight technicians with quick death should they do that!

What you gonna do...beat em silly with your guitar?

oh..btw, I went to a Guitar Center to look at PRS SE...I didn't hook it up...but it was disaapointing...looks so cheap.

 

[sdn1977]

i have already threatened the overnight technicians with quick death should they do that!

Sorry tuss - you're just gonna get called! I called our pharmacist a whole bunch of times. The good thing is the dop scheduled that pharmacist for just pyxis for about a month or so....no particular time on or off & no dispensing duties.

Pyxis only brings in their own people for about a week or so, at least in my location. Its probably dependent on how much service you "buy". So...nursing needs it a lot & always at night. OR needs it a lot (you've gotta get the anesthesiologists on board really fast or the OR will drive you nuts).

Plan to live "weird" hours - but.....once its done....you'll just put out fires...or have nursing want you to find who is taking the controlled drugs. Ugh!

 

[tussionex]

the pxyis anesthesia cabinets are on backorder. they are now an FDA regulated device as they are allegedly within 15 feet of the patient.

i'm planning on having no life for a while!