SDN - you've had friends make FATAL mistakes? I am a new practioner and try to be so careful but I've already made one error that reached the patient (long story but more of a systems error because the pre-typed form was incorrect). How did they cope? I just don't know how I could go on as a pharmacist knowing that I was the reason someone died. What kind of mistakes were they?
What is your checking technique? I want to make sure this never happens to me but I know that humans are imperfect and we are bound to make mistakes.
Yep....I've had friends who have made fatal mistakes & yes....it is hard to go on. One left the profession (went to law school & is now specializes in pharmacy law), one actually committed suicide (not over this, but it was certainly contributory) & all the others have received professional counseling. The errors were things like dosing narcotics in peds, mixing the wrong drug for an intrathecal chemo, contaminating an injectable for intrarticular use & simple....just filling the wrong drug than the label stated & no one caught it.
What is my checking technique? As tussionex said....do the SAME THING IN THE SAME MANNER EACH & EVERY TIME. It doesn't matter if you're mixing tpns, checking tpns made by techs, checking rxs, filling rxs or administering vaccines. Sometimes...I'll get a "feeling" that I've not done something right - somehow my rhythm was "off". I start back over & bingo - I find an error. If I get interrupted - I start over from the beginning (yep - put the tablets back in the bottle & recount). I'm really good at "tuning out" noise & distraction. I'll let the phone ring rather than interrupt my filling if I've started a process which I can't start over - a tpn for example.
Each time must be the same & it must work for you. The techs HATE this & I can understand why. Each of us has our own system (for example....I won't check a tpn made by a tech until he/she has turned all the labels to the front - why??? They know I expect them to have read that label the last time they put it down. Now...they probably don't,, but if my expectation has made them catch their own error once - it was of benefit. Its also how I finish when I mix a tpn or fill anything. All labels face me.
For techs to work with different pharmacists individual systems, it requires flexibility. I admire them & will often praise them.
But...I never, ever let someone rush me (unless its a code & I still will read the label of each carpuject before handing it across to the nurse).
Good luck! You'll make a mistake & you'll make more than one. First, own up to it. Don't "blame" anyone or any system (I know you aren't blaming the system here). If it was a system error - that was "contributory", but doesn't get you out of doing your job. This will often happen when First Data Bank won't get the "advisory labels" attached to a drug (First Data Bank is the company all pharmacy computer systems buy their drug data bases from). Just because it doesn't "print" doesn't mean you don't have to apply your own cautionary label & counsel. The system is designed to help, but it is your job to catch wrong orders - pretyped or handwritten.
So....take responsibility; contact the pt, prescriber & your own supervisor when it occurs; think about what factors caused you to make the error; change what you need to change about or within yourself then move on. If you can't move on, seek counseling. Be sure to have a good sounding board. Someone outside the profession, but close to you (of course...don't divulge the circumstances or person affected) who you can confide in. An SO is good. That helps to keep you grounded & realize you are still human & fallible.
Good luck! Treat each order as if you were filling it for your own child - that will help slow you down if you need to. We've all been there so you are not alone.
Would fatal mistakes be grounds for termination? For example, giving too high a dose of warfarin to a patient who eventually bleeds to death? It's just scary to think that I'm going to be approving everything that goes out of the pharmacy without anyone double checking me. Plus with the volume and short-staff... 😱
