Transfer misfill: who is to blame?

[BenJammin]

Interesting situation at work today. Every once in awhile I will work a shift at my hospital's outpatient pharmacy where it is absolutely insane. Today I was at the final verification station and counseled brand new patients on their medication. Patient gets a brand new prescription for trazodone 50 mg transferred from Walmart and this was the conversation:

Me: Have you ever taken this medication before, ma'am?
Patient: No I haven't but it's supposed to help me ease the pain in my lower back.
Me: Trazodone at bedtime is normally prescribed for sleep or mood disorders.
Patient: I don't have that! Why are you calling my medication by such a weird name? There is no z in tramadol

Oh. Damn. I call up the Walmart to reference the prescription number and they said it's clearly tramadol 50 mg. Staff pharmacist who transferred it wrote down "trazodone 50" on the prescription and says that the Walmart pharmacist said that it was correct after it was repeated back to him.

So I ask you: who is to blame for the error? What if the patient had taken the medication home, ingested it, and was sent to the hospital due to a reaction? Luckily the patient never had possession of the medication but I'm curious as to who ultimately gets the short end of the stick.

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[zelman]

Interesting situation at work today. Every once in awhile I will work a shift at my hospital's outpatient pharmacy where it is absolutely insane. Today I was at the final verification station and counseled brand new patients on their medication. Patient gets a brand new prescription for trazodone 50 mg transferred from Walmart and this was the conversation:

Me: Have you ever taken this medication before, ma'am?
Patient: No I haven't but it's supposed to help me ease the pain in my lower back.
Me: Trazodone at bedtime is normally prescribed for sleep or mood disorders.
Patient: I don't have that! Why are you calling my medication by such a weird name? There is no z in tramadol

Oh. Damn. I call up the Walmart to reference the prescription number and they said it's clearly tramadol 50 mg. Staff pharmacist who transferred it wrote down "trazodone 50" on the prescription and says that the Walmart pharmacist said that it was correct after it was repeated back to him.

So I ask you: who is to blame for the error? What if the patient had taken the medication home, ingested it, and was sent to the hospital due to a reaction? Luckily the patient never had possession of the medication but I'm curious as to who ultimately gets the short end of the stick.

The phone company. The problem obviously occurred during transmission.

 

[Rukn]

Thats why I request to have transfers faxed over or have people bring in the medicine bottles with the label on them

 

[a student]

Probably walmart... since your staff did repeat it back to him... But unless the call was recorded, there is no proof of who said what

 

[Corpseman]

I always document on my transfers that I get that I repeated back the information to the sending pharmacist.

 

[confettiflyer]

Tricky. We'll never know who heard what/who said what and where the momentary lapse happened.

But good catch. Damn.

 

[Ackj]

Blame doesn't matter for errors anymore. Also, this was a "good catch" and not quite an error, although it was pretty close. Should still be reported. Verbal orders are always a weak link with minimal proof of what actually occurred.

 

[PharFromNormal]

I'd say both. The problem occurred in a process that involved the two individuals. More could have been done on both ends.

 

[owlegrad]

I'd say both. The problem occurred in a process that involved the two individuals. More could have been done on both ends.

I am curious what more can be done other than reading back the order and getting confirmation that it's correct?

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[owlegrad]

Blame doesn't matter for errors anymore.

Not sure the various boards of Pharmacy agree with you.

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[Sine Cura]

You repeating back the information doesn't work if the person on the other line is a *******.

One time I questioned whether a discharge Rx was supposed to be Prozac 40 mg BID and the other guy said yes. This patient had no history at any CVS. It was actually Protonix.

Ultimately you are responsible because you dispensed the medication so I would request a fax of the original Rx if it's never been filled before. If I give a on-hold Rx over the phone, I always look at the original as well. At least CA allows for fax communication of transfers "directly" between two pharmacists.

A misfill is a misfill. I had a friend who was disciplined for wrong quantity of meclizine (30 instead of 90).

 

[FarmD711]

This is why I hate phone ins so much. It drives me crazy when offices constantly call all day phoning in non emergency rxs. There is no reason these shouldn't be escripted or faxed. Patients are out at risk by phone ins and there should be nearly no reason why they are still used with the prevalence of escripts. Especially when the people calling them in half the time have no idea what they're doing.

 

[JanuviaGrl]

This is why I hate phone ins so much. It drives me crazy when offices constantly call all day phoning in non emergency rxs. There is no reason these shouldn't be escripted or faxed. Patients are out at risk by phone ins and there should be nearly no reason why they are still used with the prevalence of escripts. Especially when the people calling them in half the time have no idea what they're doing.

This just hits the nail right on the spot. Phone ins, especially voicemails are such a big hassle. I always call back to verify most voicemail rxs. Most times the nurses/med assts or whoever they are clearly do not know what they are talking about, you can hardly make out the name of the med or doctors name. Voicemails from some doctors are even worst - no pt DOB, DEA or phone #. Do they expect you to guess all that info?


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[genesis09]

Ah, the joy of the voicemail all done in one breath. Really, you need to slow down and take pauses. There are some which you have to call back because you can't understand them.

 

[zelman]

This just hits the nail right on the spot. Phone ins, especially voicemails are such a big hassle. I always call back to verify most voicemail rxs. Most times the nurses/med assts or whoever they are clearly do not know what they are talking about, you can hardly make out the name of the med or doctors name. Voicemails from some doctors are even worst - no pt DOB, DEA or phone #. Do they expect you to guess all that info?


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IT SAYS "DOXYCILLIN", OKAY? Just fill it!

 

[Amicable Angora]

IT SAYS "DOXYCILLIN", OKAY? Just fill it!

That's with the Omeprafloxacin right?

 

[owlegrad]

To go with the clonazipine and hyraloxizine.

 

[PharFromNormal]

I am curious what more can be done other than reading back the order and getting confirmation that it's correct?

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Can always to more... The question is if you'd be willing to actually consider it or take the time to do it. Fax the hard copy as a cover. Randomly call back and ask when you are paranoid they messed it up? Hand deliver a hard copy? Conference call in a nurse? All probably unrealistic options but a prosecuting attorney could certainly get you to admit that you *could* do these things.

 

[504poboy]

Interesting situation at work today. Every once in awhile I will work a shift at my hospital's outpatient pharmacy where it is absolutely insane. Today I was at the final verification station and counseled brand new patients on their medication. Patient gets a brand new prescription for trazodone 50 mg transferred from Walmart and this was the conversation:

Me: Have you ever taken this medication before, ma'am?
Patient: No I haven't but it's supposed to help me ease the pain in my lower back.
Me: Trazodone at bedtime is normally prescribed for sleep or mood disorders.
Patient: I don't have that! Why are you calling my medication by such a weird name? There is no z in tramadol

Oh. Damn. I call up the Walmart to reference the prescription number and they said it's clearly tramadol 50 mg. Staff pharmacist who transferred it wrote down "trazodone 50" on the prescription and says that the Walmart pharmacist said that it was correct after it was repeated back to him.

So I ask you: who is to blame for the error? What if the patient had taken the medication home, ingested it, and was sent to the hospital due to a reaction? Luckily the patient never had possession of the medication but I'm curious as to who ultimately gets the short end of the stick.

Yeah this happened to me once. Now, I get a copy of the prescription faxed to me. I don't do oral transfers unless there is a copy a faxed prescription on file. No ifs or buts.