Pharmacist Errors in the Hospital

[Saiyo]

What does everyone think about these mistakes that have happened in hospital pharmacy?

Eric Cropp weighs in on the error that sent him to prison
Really, my only explanation for this mistake is that the tech must have had a "fugue state" like on Breaking Bad while she was mixing this IV. I thought that they must have been out of NS bags and mixing their own, but nope, the tech just decided to push 3 vials of concentrated nacl into an empty bag to mix the chemo with. GENIUS...later on she testified that something seemed "strange" about her IV...to which my only response is...ORLY?? While yes, its on the pharmacist to catch that mistake, what the heck, tech...

How Technology Led a Hospital To Give a Patient 38 Times His Dosage | Backchannel
Ok, here the pharmacist screwed up. I guess they were in a hurry and weren't used to using technology since it was the early 2000s? But come on.... what was going through nurses mind when she was giving 38 tablets of bactrim? She would've needed two cupped hands or like a sandwich bag to carry that many tablets and didn't think it was worth a call to someone?

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[lord999]

What does everyone think about these mistakes that have happened in hospital pharmacy?

Eric Cropp weighs in on the error that sent him to prison
Really, my only explanation for this mistake is that the tech must have had a "fugue state" like on Breaking Bad while she was mixing this IV. I thought that they must have been out of NS bags and mixing their own, but nope, the tech just decided to push 3 vials of concentrated nacl into an empty bag to mix the chemo with. GENIUS...later on she testified that something seemed "strange" about her IV...to which my only response is...ORLY?? While yes, its on the pharmacist to catch that mistake, what the heck, tech...

How Technology Led a Hospital To Give a Patient 38 Times His Dosage | Backchannel
Ok, here the pharmacist screwed up. I guess they were in a hurry and weren't used to using technology since it was the early 2000s? But come on.... what was going through nurses mind when she was giving 38 tablets of bactrim? She would've needed two cupped hands or like a sandwich bag to carry that many tablets and didn't think it was worth a call to someone?

1. Eric's tech was planning a wedding and wasn't paying attention. There's a couple of discussions on this matter as she really wasn't all that apologetic.

2. Sure, of course you can have safety, but that is if you're willing to spend the money on actual personnel. My hard rejoinder to anyone who says we can make this like the aircraft industry is that planes don't have to take off if they feel uncomfortable, they have mandated staffing requirements and rest (trying pulling that on residents), and they fly only routine routes. And you exclude military flights that more resemble the medical environment? Want to know how many crashes and KIA pilots there are in the military due to errors and omissions on both the fixed wing and the rotary staff?

 

[owlegrad]

I always thought that Bactrim one was nuts. Nuts that the nurse didn’t think it was worth doublechecking and nuts that the patient sat there and swallowed that many tablets.

 

[BidingMyTime]

I always thought that Bactrim one was nuts. Nuts that the nurse didn’t think it was worth doublechecking and nuts that the patient sat there and swallowed that many tablets.

Indeed. Granted the patient was 16.....and 16 year old's aren't smart. At least I wasn't when I was 16 (although I sure thought I was!) So, I can see a sick 16 year in a hospital being told by a nurse to take their medicine, that they would just do it.

 

[KimChiSlap]

36 tablets of Bactrim DS in one dose?
There's a pretty clearly something that is questionable in this setting.
Does the nurse tell the patient to take these large pill over and over and over again over a course of 5-15 minutes?
Its pretty hard not to notice that something might be wrong. Gosh.

 

[Rouelle]

I’m surprised they actually had 38 bactrim tabs in a bin in their Pyxis

 

[quickpic007]

What does everyone think about these mistakes that have happened in hospital pharmacy?

Eric Cropp weighs in on the error that sent him to prison
Really, my only explanation for this mistake is that the tech must have had a "fugue state" like on Breaking Bad while she was mixing this IV. I thought that they must have been out of NS bags and mixing their own, but nope, the tech just decided to push 3 vials of concentrated nacl into an empty bag to mix the chemo with. GENIUS...later on she testified that something seemed "strange" about her IV...to which my only response is...ORLY?? While yes, its on the pharmacist to catch that mistake, what the heck, tech...

This case actually helped lead me to community practice. At my current employer there are so many software stops and surveillance cameras, I am fairly certain I can get a bailout if my techs screw up that badly.
I hope he is gainfully employed again. I have no idea how these trials work but why plead out? No way a jury of peers would convict I think.

 

[mustang sally]

The Eric Cropp case always made me sad. I could see him losing his license or something, but I don't think he should have gone to prison.

 

[npage148]

You underestimate how stupid juries can can and that he "killed" a kid it would be risky to let a jury decided your fate

I wonder if a bench trial was possible. I'd probably let a judge (with a decent history) decide my life

 

[Saiyo]

This case actually helped lead me to community practice. At my current employer there are so many software stops and surveillance cameras, I am fairly certain I can get a bailout if my techs screw up that badly.
I hope he is gainfully employed again. I have no idea how these trials work but why plead out? No way a jury of peers would convict I think.

He ended up losing his license. It's really sad- for us in the know we can see how stupid and unfortunate of a situation this was for all parties involved, but to the public, all they see is that a pharmacist wasn't doing his job. Heck, in school they showed this video to scare us and for a long time I was terrified of being a hospital pharmacist. This is what they mean when they say techs make or break you, we're the fall guys, and to this day I'm scared that I might eventually be caught up in a similar situation.

 

[BidingMyTime]

There are so many sad and horrific cases of deaths due to medical errors on everyone's part (doctors, nurses, pharmacists, etc.) Even the best humans make errors, none of us are immune to this. Certainly maintaining a good knowledge base, and working in a place with trained technicians and with a good system to minimize errors will help minimize errors, but even that can't completely prevent them. Don't be afraid to take whatever amount of time is necessary to safely do something.....I think it's better to be fired, then to lose ones license for killing someone.

 

[Truthspeaker]

The second example is why I never order a medication as mg/kg. I don't mind if an "orderable" displays mg/kg suggestions. EVERY healthcare provider ordering medications should calculate the dose on a calculator and enter the appropriate units (tablets, mg, units, etc.) as the dose.

No offense, but the weight based orderables were designed for lazy people who enjoy that feature so they don't have to get a weight on the patient, don't have to open a reference AND generally prefer a one-size fits all to medicine. I'm seeing tons of doctors just order X mg/kg without a weight even in the chart. Then the poor pharmacist has to be paging to tell them that their dose for a child is three times bigger than an adult dose. Example: Ceftriaxone 100 mg/kg on a 60 kg kid is 6 grams. Maximum adult dose is 2 grams.

 

[lord999]

I inactivated my license in OH in protest of that. I am actually ok with a revocation in cases where the pharmacist actively commissioned the error (was impaired on duty, recklessly disregarded procedure like not labeling a bag being sent for a non-stat order), but in this case, it was clearly a tragic accident, and I do think the permanent nature of the revocation was unfounded given the open evidence (I would be ok with a suspension on command responsibility grounds, but that still gives Eric a way in at some time). My professional takeaway was honestly that if you screw up like that, you should do your best to cover up, and management should figure out a way to bury the issue in paperwork, because you have nothing to lose anyway in that circumstance, justice be damned. That's why I turn a blind eye to those issues now.

 

[PharmDBro2017]

The second example is why I never order a medication as mg/kg. I don't mind if an "orderable" displays mg/kg suggestions. EVERY healthcare provider ordering medications should calculate the dose on a calculator and enter the appropriate units (tablets, mg, units, etc.) as the dose.

No offense, but the weight based orderables were designed for lazy people who enjoy that feature so they don't have to get a weight on the patient, don't have to open a reference AND generally prefer a one-size fits all to medicine. I'm seeing tons of doctors just order X mg/kg without a weight even in the chart. Then the poor pharmacist has to be paging to tell them that their dose for a child is three times bigger than an adult dose. Example: Ceftriaxone 100 mg/kg on a 60 kg kid is 6 grams. Maximum adult dose is 2 grams.

What source are you citing? Max pediatric dose for a serious infection indication is 80-100mg/kg/day in divided doses, maximum of 4000mg daily. Adults can receive 2g q12h as well, depending on indication.


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[zelman]

The second example is why I never order a medication as mg/kg. I don't mind if an "orderable" displays mg/kg suggestions. EVERY healthcare provider ordering medications should calculate the dose on a calculator and enter the appropriate units (tablets, mg, units, etc.) as the dose.

No offense, but the weight based orderables were designed for lazy people who enjoy that feature so they don't have to get a weight on the patient, don't have to open a reference AND generally prefer a one-size fits all to medicine. I'm seeing tons of doctors just order X mg/kg without a weight even in the chart. Then the poor pharmacist has to be paging to tell them that their dose for a child is three times bigger than an adult dose. Example: Ceftriaxone 100 mg/kg on a 60 kg kid is 6 grams. Maximum adult dose is 2 grams.

Really the dose would be great to get as both mg/kg and mg in order to allow for a double check (especially with drugs like Bactrim where the dose may be inadvertently calculated using the wrong active ingredient).

 

[Truthspeaker]

What source are you citing? Max pediatric dose for a serious infection indication is 80-100mg/kg/day in divided doses, maximum of 4000mg daily. Adults can receive 2g q12h as well, depending on indication.


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There is no reference for a 6 gram dose, that was my point, I was talking about a single dose with runaway mg/kg dosing...this is about dosing errors. It's not just Ceftriaxone but that is a classic example of physicians ordering mg/kg dosing when they KNOW they don't want to give more than a 2 gram dose.

My point is physicians should stop their set it and forget it order style of ordering x mg/kg when they KNOW the maximum dose. They are just trying to put the orders in as fast as possible and get back to the lounge or move onto the next patient. Unless you pharmacists like paging about dose-capping all the time. I know 99% of these mistakes are caught by the pharmacist and corrected, but it is delaying antibiotic administration times. The mistake in the example above certainly wasn't caught by three separate healthcare professionals though...

Say you are a doctor and a 50 kg kid comes in with meningitis. You know the 2 gram ceftriaxone is accessible on the floor. Why are you wasting time ordering 100 mg/kg, waiting for the pharmacist to page you to change it to 2 grams and fix the order. It is a sad practice for sure. I looked at the metrics, there are some doctors at my hospital who have a time to antibiotic administration time that is on average 25 minutes longer than other physicians. It's no mystery why...these are the mg/kg guys that don't just cap the dose from the get go.

 

[Truthspeaker]

Really the dose would be great to get as both mg/kg and mg in order to allow for a double check (especially with drugs like Bactrim where the dose may be inadvertently calculated using the wrong active ingredient).

I agree, but they did have both the mg/kg and the mg administered shown to them. The dose of trimethoprim was displayed for both the pediatric resident AND the pediatric pharmacist. The number of tablets was also displayed. Clearly, they did not check the screen closely and were careless. Here is a document showing what they saw prior to allowing that order through.

http://www.himssasiapac.org/sites/d...PabloGarciaAndTheFailingOfSMARTHealthcare.pdf

I understand when they Monday Morning quarterback they wanted alarms to go off to stop them from allowing the order through, but none of them carefully did their job in that case and allowed that kid to get hurt bad.

 

[Saiyo]

I agree, but they did have both the mg/kg and the mg administered shown to them. The dose of trimethoprim was displayed for both the pediatric resident AND the pediatric pharmacist. The number of tablets was also displayed. Clearly, they did not check the screen closely and were careless.

That is pretty careless all around. I occasionally see orders for 4gm zofran or 1mg vancomycin. Do you think pharmacy would get a call to send their 1mg dose of vancomycin or 1000 zofran vials?

 

[BidingMyTime]

I'm seeing tons of doctors just order X mg/kg without a weight even in the chart. Then the poor pharmacist has to be paging to tell them that their dose for a child is three times bigger than an adult dose. Example: Ceftriaxone 100 mg/kg on a 60 kg kid is 6 grams. Maximum adult dose is 2 grams.

Yes! This is such a pet peeve. First I have to call the floor and try to find out the weight of the kid. Then after doing the math, I have to track down the doctor to ask if he really meant to give a preschooler a dose over an adult dose (of course s/he didn't.....) I don't mind doing the math, but at least doctors need to have the weight before ordering anything based on weight.

My professional takeaway was honestly that if you screw up like that, you should do your best to cover up, and management should figure out a way to bury the issue in paperwork, because you have nothing to lose anyway in that circumstance, justice be damned. That's why I turn a blind eye to those issues now.

This. Which of course is what ISMP and good protocol has fought against for years. If mistakes are non-punitive, then they can be openly shared, everyone can learn from them, and by learning them, hopefully prevent those mistakes from being made in the future. Not to mention, the pt can get the best care if harm is done, when the mistake is out and open (not applicable to Cropp's case, but certainly applicable to others.) When people fear punitive retribution, it's more likely mistakes will be hidden, and this is bad all around.