Started my new pharm job! Made a mistake already - ??

[SexyPlexi]

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So I worked at the hospital pharmacy for my new job this week! I LOVED it. It was very interesting. Anyway...during the day yesterday (my first day in the pharmacy) I filled a prescription wrong!! The pharmacist didn't catch it and it got checked and sent up. The RN caught it luckily and sent it back...but I am curious to know how serious of a mistake it was. The order was for Retivase and I filled it with Activase. Does anyone have any idea? Apparently Retavase is a thrombolytic agent and I found this on Activase:
What conditions does this medication treat?

Activase IV is used to treat the following:
Heart Attack, Acute Blood Clot in the Heart, Acute Blood Clot in a Blood Vessel Supplying the Lungs, Acute Thromboembolic Stroke
Activase IV may also be used to treat:
Syndrome characterized by Anemia and Renal Failure, Blockage or Closing Off of Blood Vessels in Retina of Eye, Unpredictable Severe Constricting Chest Pain, Blood Clot in an Artery, Blood Clot in a Deep Vein, Blood Clot in an Artery of the Kidney, Blood Clot of Vascular Access Device



So...are these drugs similar? How much harm could this have caused if it wasn't caught?

I am just curious. It definitely scared me that I made a mistake.

 

[WVUPharm2007]

One is an analog of the other and they both lyse clots. I think retavase just lasts longer...that's about it.

 

[SexyPlexi]

Oh ok. Well that is a little reassuring. He described it as the order was...something I can't remember...and I filled it with a heart attack med. So that sounded pretty scary to me!

Thanks! I can't wait until I know what all these things are that I am filling! Hospital is really interesting. The people are so laid back and nice too. So far I really like it. I think I saw one of the pharmacists on SDN today! LOL awesome. There are a LOT of pharmacists there. Probably ~8 staff on at a time and ~5 clinical on at a time. They are starting to put the clinical ones on the floors little by little so they can interact with the nurses and doctors more and help with dosing and interactions and stuff. I feel so lucky to be there and it's such a great environment. Another pharmacist started the same day as me...he is my age and just graduated. I sure do wish I was there already!

 

[SexyPlexi]

Oooh and I even got to do some compounding today! It was probably one of the most simple ones of course - being my second day - but eventually I think I will be able to do IVs too! Eeee! And I am just PRN so I didn't have to take the pay cut. I'll work like 2 weekends a month.

 

[Pianopooh]

Grats to your new job SexyPlexi! I'm glad you enjoyed your compounding experiences. Remember, 3 way check! Rx, drug/label, Rx! 🙂

 

[Old Timer]

Just so you know, techs and Pharmacy Students DO NOT make mistakes. The Pharmacist made the mistake. That's why he checks your work and not the other way around.

It's always good to review what went wrong and why to see if the error was human or systemic as well as human....

 

[SexyPlexi]

Just so you know, techs and Pharmacy Students DO NOT make mistakes. The Pharmacist made the mistake. That's why he checks your work and not the other way around.

It's always good to review what went wrong and why to see if the error was human or systemic as well as human....

Thanks for the reassurance Old Timer. Even though I felt bad that I didn't double check what I grabbed, I actually did feel like I wasn't really THAT much to blame since the pharmacist checked it and it WAS my first day. I would think that the pharmacists would have checked my work more carefully at the least. We sign off on the ones we fill so it seems like it would have been a good idea to look closely at the ones with the newbie's initials.

Pianopooh, I will start the 3 way check next time I work. 🙂 I'm only PRN so it's just 2 weekends a month...just enough to learn! Then by next summer when I apply I will have a year under my belt. I'm feeling even better about this decision now that I have dipped my toe in a little. I like that the pharmacists at the hospital sit down...lol

 

[Priapism321]

So I worked at the hospital pharmacy for my new job this week! I LOVED it. It was very interesting. Anyway...during the day yesterday (my first day in the pharmacy) I filled a prescription wrong!! The pharmacist didn't catch it and it got checked and sent up. The RN caught it luckily and sent it back...but I am curious to know how serious of a mistake it was. The order was for Retivase and I filled it with Activase. Does anyone have any idea? Apparently Retavase is a thrombolytic agent and I found this on Activase:
What conditions does this medication treat?

Activase IV is used to treat the following:
Heart Attack, Acute Blood Clot in the Heart, Acute Blood Clot in a Blood Vessel Supplying the Lungs, Acute Thromboembolic Stroke
Activase IV may also be used to treat:
Syndrome characterized by Anemia and Renal Failure, Blockage or Closing Off of Blood Vessels in Retina of Eye, Unpredictable Severe Constricting Chest Pain, Blood Clot in an Artery, Blood Clot in a Deep Vein, Blood Clot in an Artery of the Kidney, Blood Clot of Vascular Access Device



So...are these drugs similar? How much harm could this have caused if it wasn't caught?

I am just curious. It definitely scared me that I made a mistake.

I am just curious, how did you "fill" this order with a drug dosed in milligrams when reteplase is dosed in units? I would say that if you mix up thrombolytics and give one that is dosed much differently, you could actually kill a patient quite easily.

 

[Old Timer]

I am just curious, how did you "fill" this order with a drug dosed in milligrams when reteplase is dosed in units? I would say that if you mix up thrombolytics and give one that is dosed much differently, you could actually kill a patient quite easily.

To me this is massive failure on the part of the pharmacy software program and the pharmacist who checked it. Newbies always make mistakes and it's up to the pharmacist to make sure everything he/she checks is accurate.

 

[Priapism321]

To me this is massive failure on the part of the pharmacy software program and the pharmacist who checked it. Newbies always make mistakes and it's up to the pharmacist to make sure everything he/she checks is accurate.

Oh, I completely agree with you, and let me clarify my previous statement, reteplase is typically dosed in units (can be converted to milligrams). I was just interested in the interpretation of this order that led to alteplase being filled.

I rarely let a technician know the potential gravity of their errors because I know that it is my job to catch the mistake (e.g., 2,500 mg levetiracetam rather than 500 mg IV, 40 mg tacrolimus PO rather than 50 mEq sodium chloride). I just let them know what they prepared is incorrect, and to find me when they are ready for me to check the order again.

 

[SexyPlexi]

Here's how easily I filled it incorrectly - they were both premade in syringes and being held in the freezer. I thought the only thing in the bag was the retivase so I reached in and grabbed it. I suppose I didn't really even look closely at it. Once I found out I filled it wrong I went to check out why I did that to avoid it in the future and I saw that there were actually TWO plastic baggies right next to each other: one with prefilled Retivase syringes and the other with prefilled Activase syringes.

 

[SpirivaSunrise]

Here's how easily I filled it incorrectly - they were both premade in syringes and being held in the freezer. I thought the only thing in the bag was the retivase so I reached in and grabbed it. I suppose I didn't really even look closely at it. Once I found out I filled it wrong I went to check out why I did that to avoid it in the future and I saw that there were actually TWO plastic baggies right next to each other: one with prefilled Retivase syringes and the other with prefilled Activase syringes.

Hmmm...couple things need to be clarified.

Obviously quite a few ways something can go wrong here. To start, how far ahead are these being reconstituted? And how are they labeled?

 

[SexyPlexi]

I am not sure how far ahead they make them. They are each properly labeled though, I was just careless. I assume they are made ("reconstituted...") in a timely manner. At least I do know that they are well aware of any expiration dates for IVs they make in advance...and the date is probably on each label too. It's a large hospital with plenty of pharmacists and they seem to be on top of things. This is presumably one of those things that just slipped by.

 

[tussionex]

I rarely let a technician know the potential gravity of their errors because I know that it is my job to catch the mistake (e.g., 2,500 mg levetiracetam rather than 500 mg IV, 40 mg tacrolimus PO rather than 50 mEq sodium chloride). I just let them know what they prepared is incorrect, and to find me when they are ready for me to check the order again.

wow, i don't usually like to be difficult on forums, but i can't disagree with you more on this point.

to NOT stress the gravity of the mistake does not allow the technician or student to learn what can and cant kill people. the two examples are pretty extreme and the tech/student should ABSOLUTLEY be told that a LARGE mistake was made! how else do you expect them to understand the serious nature of what they are doing.

techs and students are there to prepare things correctly, and they are the first "check" if they are making it.
yes, it's our job to catch the mistakes, and it's on us if it gets out the door, but i believe pharmacy is a team effort and support staff need to be adequately trained in the gravity of what they are doing! i think you may be doing your staff a disservice if you dont do that.

 

[Priapism321]

wow, i don't usually like to be difficult on forums, but i can't disagree with you more on this point.

to NOT stress the gravity of the mistake does not allow the technician or student to learn what can and cant kill people. the two examples are pretty extreme and the tech/student should ABSOLUTLEY be told that a LARGE mistake was made! how else do you expect them to understand the serious nature of what they are doing.

techs and students are there to prepare things correctly, and they are the first "check" if they are making it.
yes, it's our job to catch the mistakes, and it's on us if it gets out the door, but i believe pharmacy is a team effort and support staff need to be adequately trained in the gravity of what they are doing! i think you may be doing your staff a disservice if you dont do that.

Point well taken, I can certainly see it that way as well. And, those were actual mistakes I have caught that just were recent enough to come to me quickly while I was typing.

 

[tussionex]

ok....sounds good...i agree with that!

😀

 

[ItsOverZyvox]

Well,

Reconstituted frozen Retavase should never be mistaken for Alteplase because prefilled Alteplase is available commercially - Cathflo and reconstitued retavase should be in the freezer in frozen syringes. And these smaller units are usually used to clear clogged IV access instead of thrombolysis for ACS or for stroke.

How would I handle it?

Me to the tech with a wink: Dude... you trying to make me lose my license and kill the patient at the same time...what the heck is wrong with you.. Just because I've done it many times doesn't mean you can too!! Now give me the right stuff.

Technician gets the message this is serious...but at the same this is light-hearted no feelings are hurt.

 

[njac]

Oh, I completely agree with you, and let me clarify my previous statement, reteplase is typically dosed in units (can be converted to milligrams). I was just interested in the interpretation of this order that led to alteplase being filled.

I rarely let a technician know the potential gravity of their errors because I know that it is my job to catch the mistake (e.g., 2,500 mg levetiracetam rather than 500 mg IV, 40 mg tacrolimus PO rather than 50 mEq sodium chloride). I just let them know what they prepared is incorrect, and to find me when they are ready for me to check the order again.

how the %$#^@#^%#@ did they come up with 40 mg of tacrolimus?

 

[Priapism321]

how the %$#^@#^%#@ did they come up with 40 mg of tacrolimus?

Prepackaging batch liquids; I never know exactly how the system breaks down for them to make such a mistake, but that is one of the worst errors I have caught (only been a pharmacist for 5 minutes though).

 

[tussionex]

Well,

Reconstituted frozen Retavase should never be mistaken for Alteplase because prefilled Alteplase is available commercially - .

good point. why is anyone going through the trouble of making Alteplase Syringes?

 

[njac]

good point. why is anyone going through the trouble of making Alteplase Syringes?

sometimes we do 5mg/50 mL for like chest tubes and stuff. If it doesn't get used we'll freeze it (I believe it's good for 30 days frozen).

 

[RxWildcat]

Just so you know, techs and Pharmacy Students DO NOT make mistakes. The Pharmacist made the mistake. That's why he checks your work and not the other way around.

It's always good to review what went wrong and why to see if the error was human or systemic as well as human....

Well I only partially agree with this, the students and techs can be held responsible to a certain extent.

 

[Omegadramon]

good point. why is anyone going through the trouble of making Alteplase Syringes?

At our hospital, we've got some 10g/10ml syringes frozen up. I saw it once called up for a patient with a stroke who needed 6mg (and the pharmacist let me know that the refridgerated syringes cost the patient $2000)... But normally we just send out the 2g cathflo vials w/sterile water.